045002620-9-15-2022-25-AS-LMUZ-CJFR6L-20220920124452

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002620
Report Date: 09/15/2022
Date Signed: 09/15/2022 10:41:48 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
03/30/2022 and conducted by Evaluator Jaclyn Avila

COMPLAINT CONTROL NUMBER: 25-AS-20220330164722

FACILITY NAME:	INN AT THE TERRACES, THE		FACILITY NUMBER:	045002620
ADMINISTRATOR:	KEENE, CLIFF		FACILITY TYPE:	740
ADDRESS:	2950 SIERRA SUNRISE TERRACE		TELEPHONE:	(530) 894-5429
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	99	CENSUS: 81	DATE:	09/15/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Cliff Keene		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident sustained serious injuries due to a lack of care and supervision.
Facility failed to seek timely medical attention

INVESTIGATION FINDINGS:

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On 9/15/2022 at 9:45 AM, Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a complaint investiation visit. LPA met with administrator Cliff Keene and discussed the purpose of the visit was to deliver complaint finding regarding the allegations above. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95.

On 3/22/2022 at 2:59 PM, Resident 1 (R1) was found on the floor of R1’s apartment at The Inn at the Terraces, after sustaining an unwitnessed fall and was transported to the hospital. Medical records revealed R1 sustained a closed fracture of R1’s right distal femur (noted “as consequence of the fall”) and had an unstageable, full thickness pressure wound on R1’s right buttock. R1 sustained healing abrasion on R1’s right elbow and left forearm and a deep tissue injury on R1’s left heel. The Wound Care Registered Nurse (RN) assessed and found R1’s wounds to include the heeling properties/scabbing of the elbow and forearm abrasion consistent with wounds that are 1-2 days old.
Cont'd on LIC 9099-C

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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 4

Control Number 25-AS-20220330164722

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: INN AT THE TERRACES, THE	FACILITY NUMBER: 045002620
	VISIT DATE: 09/15/2022

NARRATIVE

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This Department determined staff neglected R1 by failing to supervise R1 appropriately and failing to check on R1. Per facility key fob records, R1 was last seen in R1’s room on 3/20/2022 at 2:56 PM. Staff were unaware of R1’s whereabouts. Although a few staff stated they saw R1 on the morning of 3/22/2022, those statement did not match the key fob records for R1’s room door. There is a preponderance of evidence obtained, that R1 was last seen in R1’s room on 3/20/2022 at 2:56 PM and R1 never left the room until discovered on 3/22/2022 at 2:59 PM. R1 sustained an unwitnessed fall in R1’s room during this time period. R1 was discovered in R1’s room on 3/22/2022 at 2:59 PM when staff smelled “a really rancid urine smell” coming from the room of R1 which was what prompted staff to check on R1. Staff discovered R1 lying on the ground mostly nude and on R1’s left side. R1 was lying on a pool of urine described size as “a basketball or two.” Staff stated, “You could really smell it (urine). It was a lot.” R1 was “not fully aware” which is not R1’s baseline. At this time staff summoned for assistance to include 911.

R1 was admitted to the hospital and diagnosed with a broken bone, pressure injuries and abrasions. Paramedics and medical staff (nurse and doctor) provided statements to support that the injuries were 1-2 days old. Blood work indicated R1 was incapacitated for at more than 8 hours which is evidence that R1 sustained the pressure injuries as a result of laying in a position for a prolonged period of time due to staff not checking on R1.

Although staff stated they saw R1 the morning of 03/22/2022. Medical evidenced supports R1 was down for a prolonged period of time resulting in pressure wounds and abrasions, in addition to R1 sustaining a fractured femur as a result of R1’s fall.

All staff interviewed, including facility Administrators admitted, although R1 was independent and did not need assistance for ADL’s, the facility policy was that every resident is checked on and accounted for at every meal. This is documented on the Resident Meal Checklist. The Resident Meal Checklist documents that R1 attended breakfast, lunch and dinner on 3/21/22, however, serving staff interviewed admitted that on occasion residents were checked off as receiving a meal that had not received a meal. It was documented that R1 did not receive breakfast or lunch on 3/22/2022 and was not checked on as per facility policy.

Cont'd on LIC 9099C

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220330164722

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: INN AT THE TERRACES, THE	FACILITY NUMBER: 045002620
	VISIT DATE: 09/15/2022

NARRATIVE

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The preponderance of evidence supports that R1 did not receive timely medical attention due to staff neglecting to check on R1 when R1 missed Breakfast on 3/22/2022. Door key fob records obtained indicate that no one entered or exited Alice’s room after 03/20/2022 at 2:56 PM when R1 was last seen in her room.

In an addition to the complaint allegations, additional deficiencies will be cited during a case management visit. Reference LIC 809 (Facility Evaluation Report).

Based on observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20220330164722

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: INN AT THE TERRACES, THE	FACILITY NUMBER: 045002620
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 09/16/2022 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all the following personal rights: (8) To be free from neglect, financial exploitation,	1 2 3 4 5 6 7	Licensee agrees to improve upon the attendance check off for meals and submit to CCLD no later than 9/16/2022.
	8 9 10 11 12 13 14	involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.This requirement is not met as evidenced by: Based upon interview, observation and documentation. The Licensee failed to ensure R1 was free from neglect. This poses and immediate health, safety and personal rights risk to Residents in care	8 9 10 11 12 13 14
Request Denied Type A 09/16/2022 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f)Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based upon interview, observation and documentation.	1 2 3 4 5 6 7	Licensee agrees to create a policy to incease follow up on assessments of residents. Policy will be provided to CCLD no later than 9/16/2022
	8 9 10 11 12 13 14	The Licensee failed to ensure R1 was provided with care and supervision which resulted in serious injury. This poses and immediate health, safety and personal rights risk to Residents in care.	8 9 10 11 12 13 14	Civil penalty assessed in the amount of $500

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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