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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001756
Report Date: 04/22/2021
Date Signed: 04/22/2021 01:01:20 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2020 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20201203161808
FACILITY NAME:COMPASS ROSEFACILITY NUMBER:
045001756
ADMINISTRATOR:KEENE, CLIFFFACILITY TYPE:
740
ADDRESS:2750 SIERRA SUNRISE TERRACETELEPHONE:
(530) 774-2705
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:48CENSUS: 48DATE:
04/22/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cliff Keene, administratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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 Neglect/Lack of Supervision:Facility staff failed to provide appropriate supervision resulting in Resident 1 (R1) sustaining serious injuries while in care.
INVESTIGATION FINDINGS:
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04/22/2021 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to deliver the results of an investigation that was conducted by Department of Social Services Community Care Licensing Investigations Branch for a complaint that was received on December 3, 2020. Before entering the facility, LPA took her temperature which registered within normal range. LPA donned appropriate PPE. Upon entrance LPA met with Administrator Cliff Keene. LPA Knight explained the reason for the visit.

Allegation: Neglect/Lack of Supervision: Facility staff failed to provide appropriate supervision resulting in Resident 1 (R1) sustaining serious injuries while in care.

Finding: UNSUBSTANTIATED

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 25-AS-20201203161808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COMPASS ROSE
FACILITY NUMBER: 045001756
VISIT DATE: 04/22/2021
NARRATIVE
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On 08/14/2020, facility staff reported to the paramedics that R1 had been refusing adequate water intake for "a few days" and had developed dry lips resulting in a crack and bleeding. Facility staff reported that R1 was yelling in pain and that they found a severe advanced stage bruise to R1's right axillary region three or four days earlier. Hospital records did not document blood on the lips or the cause of the hematoma.

An interview with the emergency room physician, was conducted and he was unable to state the cause of the hematoma. Facility records document that the hematoma was first observed on 08/12/2020. Facility staff were interviewed, and they did not know the cause of the hematoma or the bloody lip. Facility staff stated R1 did not sustain any serious falls or serious injuries to have caused the hematoma.

This investigation concludes that although R1 sustained a serious injury, it is unclear if the injury was sustained due to a neglect/lack of supervision by facility staff.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.

An exit interview was conducted. A copy of the report was given o facility administrator Cliff Keene. No deficiency.

SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2020 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20201203161808

FACILITY NAME:COMPASS ROSEFACILITY NUMBER:
045001756
ADMINISTRATOR:KEENE, CLIFFFACILITY TYPE:
740
ADDRESS:2750 SIERRA SUNRISE TERRACETELEPHONE:
(530) 774-2705
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:48CENSUS: 48DATE:
04/22/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cliff Keene, administratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
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9
Neglect/Lack of Care: Facility staff failed to ensure that R1 received prescribed medication immediately upon their return from the hospital.
INVESTIGATION FINDINGS:
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04/22/2021 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to deliver the results of an investigation that was conducted by Department of Social Services Community Care Licensing Investigations Branch for a complaint that was received on December 3, 2020. Before entering the facility, LPA took her temperature which registered within normal range. LPA donned appropriate PPE. Upon entrance LPA met with Administrator Cliff Keene. LPA Knight explained the reason for the visit.

Allegation: Neglect/Lack of Care: Facility staff failed to ensure that R1 received prescribed medication immediately upon their return from the hospital.

Findings: SUBSTANTIATED

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20201203161808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COMPASS ROSE
FACILITY NUMBER: 045001756
VISIT DATE: 04/22/2021
NARRATIVE
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On 08/08/2020, R1 was admitted to a local hospital for a chief complaint of "arm pain." R1 was discharged the same day. A fentanyl patch was prescribed for pain management with instructions to place the patch on the skin every third day. Discharge instructions included picking up the fentanyl patch from any pharmacy with a printed prescription.

Facility records document that the fentanyl patch was applied on R1 on 08/09/2020 due to miscommunication from the hospital. Reporting party (RP) stated that they visited R1 on 08/09/2020 and observed the fentanyl patch was not applied on R1. RP stated they went to the pharmacy to obtain the fentanyl patch on 08/09/2020 and provided it to the facility so that they could apply it on R1.

Facility staff reported that either Staff 1 (S1) or the on-duty med-tech would have been responsible for reading the discharge instructions and ensuring that the newly prescribed medication is filled. S1 admitted that either they or the on-duty med-tech would have been responsible for reading R1's discharge instructions and obtaining the newly prescribed medication.

Based on the interviews and evidence obtained, the preponderance of evidence standard has been met, therefore, the above allegation is found to be substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal rights were provided, and an exit interview conducted.

SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20201203161808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COMPASS ROSE
FACILITY NUMBER: 045001756
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2021
Section Cited
CCR
87465(a)(5)
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87465 (a) (5) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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The licensee to provide training to facility staff to ensure that they know the protocols for reviewing hospital discharge instructions and ordering prescription medications for residents.
This training shall be completed within one week.
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Based on the Investigator’s interviews of staff it was determined that staff did not fill R1’s new prescription for pain medication upon discharge from hospital which poses an immediate health and safety risk to residents in care.
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Proof of completion shall be sent to the licensing agency by 4/29/2021.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5