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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002891
Report Date: 01/31/2023
Date Signed: 01/31/2023 12:59:12 PM

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
09/20/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20220920132744
FACILITY NAME:FOOTHILL COTTAGEFACILITY NUMBER:
045002891
ADMINISTRATOR:ABEJO, KRISTINEFACILITY TYPE:
740
ADDRESS:3064 CEANOTHUS AVENUETELEPHONE:
(530) 809-0418
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:6CENSUS: 4DATE:
01/31/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Kristine Abejo - licenseeTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident developed a pressure injury while in care - SUBSTANTIATED
Staff are not following treatment plan as prescribed for resident - SUBSTANTIATED
INVESTIGATION FINDINGS:
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01/31/2023 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with licensee Kristine Abejo. The purpose of this visit was to deliver the results of a complaint investigation. Prior to initiating the visit, LPA completed 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 mask, gloves.
During the course of the investigation the licensee, staff, and clients were interviewed. LPA received the following Enloe Physicians Orders, Enloe Exercise Program, Enloe Wound Center, Progress Notes, related emails, Physicians Report, X-Rays from Enloe Medical Center, Needs and Service Plan, bathroom log, Staff Roster, and Facility resident roster.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
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-20220920132744
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: FOOTHILL COTTAGE
FACILITY NUMBER: 045002891
VISIT DATE: 01/31/2023
NARRATIVE
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Resident developed a pressure injury while in care – SUBSTANTIATED

On 8-25-2022, R1 was noted to have a "blister" on their tail bone. Enloe Home Health was notified of the blister. On 9-03-2022, the blister popped, and a liquid came out. Enloe Home Health was notified. On 9-09-2022, Enloe Home Health diagnosed the blister as a stage 2 pressure ulcer. Staff was advised to keep the ulcer clean and covered. On 9-15- 2022, R1 had a follow up appointment and the ulcer was re-classified as a stage 4 ulcer. R1 is non-ambulatory and relies on staff to transfer them in and out of bed. According to staff, R1 wakes up around 0630 hours and is placed in their wheelchair until around noon, when they are placed back in bed for an hour to take a nap. R1 is taken out of bed and placed back into their wheelchair until 1930 hours when R1 spends the remainder of the night in bed. Staff advised that R1 can rotate themself if needed, but staff rotates R1 three times a night. R1 advised staff allow them to sit in a dirty diaper during the night. Staff advised R1 does not soil their diaper during the night and if they do, its "only a little wet" and R1 is left in the little wet diaper. Facility staff were advised by Enloe Home Health to keep R1 off of their pressure ulcer and rotate R1 every two hours. The facility Administrator Kristine Abejo advised due to R1 wearing hearing aids, staff could not rotate R1. Enloe Home Health advised staff to keep R1's pressure ulcer clean and covered. Abejo advised R1 did not have a pressure ulcer, but the infected area was an infection. Abejo advised she could not follow Enloe's Home Health care orders or else R1 could have died. Note: Abejo is not a nurse nor does she have any medical training to make this assumption. Abejo freely admitted to not following Enloe's Home Health orders.

Enloe Home Health staff, Rachel Zanon, Vashty Kyle, and Corinne Richter all advised that Abejo directly informed them she was not going to follow the care instructions given by Enloe Home Health.

Due to R1 sitting in their wheelchair all day, not being rotated at night, and Abejo failing to follow the care directions from Enloe Home Health, R1's pressure ulcer developed from a stage 2 ulcer to a stage 4 ulcer. The allegation of Neglect/Lack of Care and Supervision is substantiated due to staff failing to properly care for R1 and going against medical professionals' care instructions.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20220920132744
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: FOOTHILL COTTAGE
FACILITY NUMBER: 045002891
VISIT DATE: 01/31/2023
NARRATIVE
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Staff are not following treatment plan as prescribed for resident - SUBSTANTIATED

During interviews the licensee stated she could not follow Enloe's Home Health care orders or else R1 could have died. The licensee freely admitted to not following Enloe's Home Health orders. Enloe Home Health staff, Rachel Zanon, Vashty Kyle, and Corinne Richter all advised that the licensee directly informed them she was not going to follow the care instructions given by Enloe Home Health.

Based on interviews the department has conducted this allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to licensee Kristine Abejo.

As a result of the resident sustaining a stage 4 pressure injury, an immediate civil penalty was assessed in the amount of $500.00 on 01/31/2023, on the attached LIC421IM.



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.

Continued on LIC9099-D
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20220920132744
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: FOOTHILL COTTAGE
FACILITY NUMBER: 045002891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
02/14/2023
Section Cited
CCR
87616
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87616(a)(b)(1)(2)(3) Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. (b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. (2) The licensee's plan for ensuring that the resident's health related needs can be met by the facility. (3) Plan for minimizing the impact on other residents. This requirement is not met as evidenced by:
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Licensee agrees to provide CCLD with a plan for preventing Stage III, IV or unstageable wounds from developing, and if they should develop what the plan is for relocation or exception request.
Violations that result in the injury of a client in care are subject to an immediate civil penalty of $500 per violation followed by $100 per day until the deficiency is corrected.
Civil penalty assessed at $500.
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Based on the department investigation the facility failed to submit a written exception for the resident’s stage IV pressure sore in a timely manner. This poses an immediate health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 02/14/2023.
Deficiency Dismissed
Type A
02/14/2023
Section Cited
CCR
87466
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87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as … physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
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Licensee agrees to provide training for all direct care and administrative staff in the proper observation of residents. The training will be conducted by a STATE APPROVED VENDOR. Licensee will schedule the training and provide CCL with the date of the scheduled training and contact information for the trainer as the POC.
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Based on the department investigation it was determined that the licensee failed to observe changes in R1's condition and follow the home health plan of care. This poses an immediate health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 02/14/2023.
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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20220920132744
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: FOOTHILL COTTAGE
FACILITY NUMBER: 045002891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
02/14/2023
Section Cited
CCR
87609
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87609(b)(2) Allowable Health Conditions and the Use of Home Health Agencies – (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (2) The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care. This requirement is not met as evidenced by:
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Licensee agrees to provide training for all direct care and administrative staff in the requirement to follow a treatment plan as prescribed for resident who is receiving home health care. The training will be conducted by a STATE APPROVED VENDOR. Licensee will schedule the training and provide CCL with the date of the scheduled training and contact information for the trainer as the POC.
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Based on the department investigation the facility failed to follow the treatment plan as prescribed for resident which resulted in the resident sustaining a stage 4 pressure injury while in care. This poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 02/14/2023.
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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5