567610000-4-29-2022-29-AS-DPEA-CE6SBK-20220506134401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567610000
Report Date: 04/29/2022
Date Signed: 04/29/2022 02:14:43 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
05/07/2021 and conducted by Evaluator Martha Guzman-Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20210507143030

FACILITY NAME:	ERTEN HOME CARE		FACILITY NUMBER:	567610000
ADMINISTRATOR:	ROSALES, KAREN		FACILITY TYPE:	740
ADDRESS:	212 ERTEN ST.		TELEPHONE:	(818) 219-5998
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Karina Antig		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility staff hit resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted on 5/14/2021 by LPAs M. Guzman Chavez and K. Dulek. During today’s visit, LPA Guzman Chavez met with Administrator, Karina Antig. Entrance interview conducted.

During the initial visit on 5/14/2021, the LPAs Guzman Chavez and Dulek conducted a physical plant tour at 10:35 a.m., interviewed facility designee at 11:05 a.m., conducted staff, resident, and family member interviews at 10:51 a.m., 11:34 a.m., and 4:40 p.m., and conducted a file review at 11:13 a.m. The LPAs also conducted a collateral visit to another one of licensee’s facilities, Happy Home Care 3 to interview staff at 12:02 p.m.

...Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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-20210507143030

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: ERTEN HOME CARE	FACILITY NUMBER: 567610000
	VISIT DATE: 04/29/2022

NARRATIVE

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...Continued from LIC 9099...

It was alleged that facility staff hit resident. It was reported that Staff #1(S1) had punched Resident #1 (R1) several times in the face. Additionally, it was reported that S1 had placed their nails on R1’s hand and ripped open the skin. Interviews conducted revealed R1 was sitting on their wheelchair and S1 was sitting on the couch while both were watching television. R1’s legs became shaky as R1 tried standing up and almost fell. S1 immediately went to help R1; however, R1 took that gesture as an attack from S1. Documents reviewed revealed that the Ventura County Sheriff’s Department was called to the facility to investigate. Per police report dated 5/06/2021, it stated ‘R1 had no marks or injuries to their face, which was inconsistent with the statement of being punched in the face’. Because of the conflicting statements given to the Sherriff’s by R1, they were ‘unable to establish that a crime had occurred’. Furthermore, interviews also revealed that R1 had a skin tear on his arm before the incident occurred that was being treated by Home Health (HH) several times a week. Interviews with family members revealed that they feel the facility takes good care of R1 and the situation was misinterpreted. Based on interviews and documentation gathered, it has been determined that the Department does not have sufficient evidence to support the allegation of “facility staff hit resident”. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued. Copy of report sent via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

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