567609809-3-14-2023-29-AS-DPEA-CQ8VWZ-20230324164848

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609809
Report Date: 03/14/2023
Date Signed: 03/14/2023 06:30:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/26/2022 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20220726161113

FACILITY NAME:	HAPPY HOME CARE 3		FACILITY NUMBER:	567609809
ADMINISTRATOR:	ROSALES, KAREN		FACILITY TYPE:	740
ADDRESS:	191 EAST GAINSBOROUGH ROAD		TELEPHONE:	(805) 370-0214
CITY:	THOUSAND OAKS	STATE:	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	03/14/2023
		UNANNOUNCED	TIME BEGAN:	06:00 PM
MET WITH:	Karina Antig		TIME COMPLETED:	06:35 PM

ALLEGATION(S):

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Due to neglect, resident developed a bed sore.
Resident is left in soiled diapers for an extended period of time.
Staff failed to safeguard resident's personal belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 07/29/2022 by LPA M. Arroyo. During today’s visit, LPA Arroyo met with Administrator, Karina Antig. Entrance interview conducted.

During the initial visit on 07/29/2022, LPA Arroyo conducted a physical plant tour at 2:40 p.m., interviewed the Administrator, one staff, three residents, one family member, and began record review of resident files at 3:46 p.m. LPA also conducted family interviews on 9/15/2022 at 2:52 p.m.

Report Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220726161113

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAPPY HOME CARE 3	FACILITY NUMBER: 567609809
	VISIT DATE: 03/14/2023

NARRATIVE

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Report Continued from LIC 9099...

It was alleged that due to neglect, resident developed a bed sore. It was reported that Resident #1 (R1) was sent to the hospital after developing a bed sore due to staff not changing the resident. Upon review of R1’s hospital’s discharge summary, it was revealed that R1 was admitted to the hospital due to a recurrent Urinary Tract Infection (UTI) and facility staff noting R1 weaker and more somnolent than the previous day. Although hospital documents noted R1 with a pressure injury, R1 was receiving Home Health (HH) services before being admitted to the hospital. Additionally, HH notes dated 07/04/2022 indicated R1 to have a stage 2 ulcer on sacral region, which the HH nurse was currently performing wound care twice a week. Interviews with family members revealed they were aware of residents having pressure injuries and stated either a HH or hospice nurse was visiting the facility to care for the pressure injuries. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the allegation “due to neglect, resident developed a bed sore”. Therefore, the allegation is deemed Unsubstantiated at this time.

It was also alleged that resident is left in soiled diapers for an extended period of time. It was reported that R1’s diaper was filthy and appeared that it had not been changed all day. Interviews conducted with residents revealed the staff checks on them frequently. Additionally, interviews with staff revealed residents’ diapers are being changed every two hours while the residents are repositioned. However, staff stated the resident’s diapers will get changed sooner if they feel the diaper requires changing. Interviews with family members revealed family members are visiting the residents every day. Additionally, family members reported staff were pretty good at changing the residents and were getting their diapers changed frequently. Furthermore, family members stated they have never had a problem with the facility and feel the residents are getting well cared for. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation “resident is left in soiled diapers for an extended period of time” Therefore, the allegation is deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220726161113

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAPPY HOME CARE 3	FACILITY NUMBER: 567609809
	VISIT DATE: 03/14/2023

NARRATIVE

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Report Continued from LIC 9099C...

It was further alleged that staff failed to safeguard resident’s personal belongings. It was reported that facility have misplaced R1’s dentures and glasses. Staff interviews revealed resident’s family have not reported anything missing from the resident’s room. Interviews conducted with family members revealed they have never had a problem with the facility and stated resident does not have much in their room other than their furniture, clothes, and a few pictures. Additionally, family members stated if something would have gone missing it would be easy to spot. Interviews with R1’s family revealed a visitor had taken R1’s dentures off while visiting R1. Furthermore, R1’s family denied R1 having anything gone missing while living at the facility. Based on interviews conducted with staff and family members of residents, the Department does not have sufficient evidence to support the allegation “resident is left in soiled diapers for an extended period of time” Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued. Report was reviewed with Administrator and a copy was given.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

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