134604299-8-24-2023-08-AS-DPOL-CV7TWX-20230830150617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 134604299
Report Date: 08/24/2023
Date Signed: 08/24/2023 12:21:32 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2020 and conducted by Evaluator Renita Hall

COMPLAINT CONTROL NUMBER: 08-AS-20200729131655

FACILITY NAME:	PARKSIDE VILLA ASSISTED LIVING		FACILITY NUMBER:	134604299
ADMINISTRATOR:	KAHNIS, KEVIN		FACILITY TYPE:	740
ADDRESS:	1685 CYPRESS DR		TELEPHONE:	(442) 271-4109
CITY:	EL CENTRO	STATE: CA	ZIP CODE:	92243
CAPACITY:	18	CENSUS: 18	DATE:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	11:48 AM
MET WITH:	Sikalalic Garcia, Manager		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Staff did not seek timely medical care for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to deliver findings. LPA was allowed entry by the Siklalic Garcia, Manager. LPA identified herself and disclosed the purpose of the visit and shared findings with the Manager.

On July 29,2020 a complaint was received regarding the alleged incident that staff did not see timely medical care for resident.

On July 24, 2020 the Licensee (LC) called Veteran's Affair (VA) via tele-health (scheduled) for Resident (R1). During the call, Licensee explained "violent" behavior to Attending Physician (AP1) to increase medication, respiradone, to "control" R1's behavior.

Continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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 08-AS-20200729131655

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PARKSIDE VILLA ASSISTED LIVING	FACILITY NUMBER: 134604299
	VISIT DATE: 08/24/2023

NARRATIVE

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AP1 advised that antipsychotic medications require medical evaluation "to rule out a medical problem, such as UTI or urinary retention." AP1 explained to licensee that UTI and urinary retention contribute to increased behaviors. Per AP1's interview and medical notes, licensee stated to AP1 on July 24, 2020 that R1 had hit a nurse and an incident report was submitted to CCLD (unknown date). No such incident report was submitted to CCLD. AP1 ordered the resident to be seen on July 24, 2020 but the client was not brought to the VA to be evaluated. This was corroborated by interviews with AP1 and Licensee.

On July 27, 2020 R1 was brought into to be seen and AP1 determined that R1 was retaining 600 cc of urine even though the resident was able to release some urine. According to AP1, anything more than 100 cc of urine is urinary retention and requires additional medical attention. AP1 ordered the Licensee to bring R1 to the ER with a recommendation of a bladder scan for the urinary retention and insertion of a foley catheter. In the interim, to rule out untreated UTI, per medical procedure according to the VA's Licensed Medical Social Worker, AP1, and AP2, that antibiotics were prescribed. AP2 during an interview on August 14, 2020, stated that the benefits of prescribing antibiotics for the UTI far outweighs untreated UTI. Any side effects from the antibiotics would not be as significant as an untreated UTI and that it would be overseen by the physician. Medical records: Resident complained of suprapubic pain for one week. This was noted by AP1 in the VA report.

July 28, 2020 Licensee was asked to come back into the office because the VA found out that they had an ultrasound machine, as well as, lab results for the urinary analysis. Lab results returned negative for a UTI but that R1 still had 600 cc of urine. AP1 ordered that the resident be taken to the ER that night. Per Licensee's interview, the resident refused to be brought to the hospital for a foley catheter, therefore, Licensee did not take R1 to the hospital. On July 29, 2020 Resident was brought to the ER for a foley catheter insertion.

During interview on August 18, 2020 with the Licensee denied that a physical or violent incident occurred. Licensee denied there was an incident that occurred regarding resident hitting staff. AP1 suspected that Licensee was lying to manipulate AP1 into ordering a medication increase. Based on LPA's interview with the Licensee, Licensee was inconsistent regarding the physical incident that R1 apparently hit a nurse. Licensee admitted that he "presented symptoms to the doctor to see what we can get for R1" to address the behaviors."
Continued on 9099C

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200729131655

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PARKSIDE VILLA ASSISTED LIVING	FACILITY NUMBER: 134604299
	VISIT DATE: 08/24/2023

NARRATIVE

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August 5,2020 R1 was seen by AP2 at the VA and an infection was ruled out, aka, not a UTI. The medical assessment was that the "it was behavioral" because the white blood cells were not elevated, only lung congestion (which is consistent with diagnosed CHF). On August 6, 2020 R1 was sent back to the hospital for pulling out the Foley catheter. Per Licensee, urologist advised that catheter is no longer needed but that the resident will continue to be evaluated. August 10, 2020 El Centro Medical ER visit - at 1853, patient is retaining 215 mL of urine; On August 14, 2020 AP2 referred to a psychiatric/geriatric physician to be seen on September 21, 2020 to determine suitability of placement or whether resident requires a higher level of care.

Based on the evidence, interviews conducted, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Licensee ignored doctor's orders to bring R1 into the VA clinic on July 24, 2020 to rule out a medical problem after tele-health consultation. After in-person visit, Licensee ignored doctor's orders for catheter insertion and did not bring the resident to the ER post-visit. R1 expressed to the physician that R1 was experiencing pain for the past week. "Change me, change me," which was expressed by R1 prior to doctor's visits, Licensee dismissed it as a dry diaper and ignored any continence issues. Interview with AP1 and medical notes indicate that the urinary retention could be from untreated prostate cancer. Hence, AP1 ordered an emergency room visit. Licensee, based on a non-medical background, did not feel like the catheter was necessary because R1 was able to void, even though the ultrasound indicated that the resident was retaining 600cc of urine. Licensee did not bring R1 to the ER on July 29, 2020 after a follow-up examination for catheter insertion.

An exit interview was conducted with Sikalalic Garcia, Manager. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator and her signature on this report confirms receipt of the Licensee Rights.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

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