150400536-11-4-2021-24-AS-MHON-C9YMPB-20211223084649

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 150400536
Report Date: 11/03/2021
Date Signed: 11/04/2021 08:25:06 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2021 and conducted by Evaluator Malia Thao

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210503141827

FACILITY NAME:	ROSEWOOD RETIREMENT COMMUNITY		FACILITY NUMBER:	150400536
ADMINISTRATOR:	BALABAN, ROCHELLE		FACILITY TYPE:	741
ADDRESS:	1301 NEW STINE ROAD		TELEPHONE:	(661) 834-0620
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93309
CAPACITY:	220	CENSUS: 151	DATE:	11/03/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Rochelle Balaban, Administrator Griscel Garcia, Memory Care Manager		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Facility staff are not administering medication as prescribed.
Facility staff are not meeting resident needs.

INVESTIGATION FINDINGS:

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On 11/3/21 at 8:45 AM, Licensing Program Analysts (LPAs) Malia Thao and Lisa Salazar arrived unannounced to conduct a complaint investigation. LPA explained reason for inspection at front desk and was granted entry.
LPAs met with Griscel Garcia, Memory Care Manager and Administrator Rochelle Balaban.

During the course of the investigation, LPAs made observations, reviewed records, and interviewed staff. Based on the observations, record reviews, and interviews, LPAs found that the facility staff were not administering medication as prescribed. R1's medication Acetaminophen 325mg tablet was started on 10/29/21 as a routine medicine to be given two tablets by mouth every 8 hours for pain. Starting from 10/29/21 to today, only 9 doses have been administered, but 7 doses were remaining on the bubble pack card not given as prescribed. All doses for 10/29/21 through 10/31/21 were given. Doses for 11/1/21 through 11/3/21 AM dose were not given and still in the bubble pack card.

Continue on LIC9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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 4

Control Number 24-AS-20210503141827

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ROSEWOOD RETIREMENT COMMUNITY	FACILITY NUMBER: 150400536
	VISIT DATE: 11/03/2021

NARRATIVE

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Continued from LIC9099.

LPA found that 3 out of 8 residents sampled showed Activities of Daily Living (ADL) logs did not match the residents basic services as shown on the residents' Physician's Report for Residential Care Facilities for the Elderly form LIC602A.

The above allegations are substantiated. Deficiencies are being cited based on LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC9909D.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and emailed to the email address on record with “Read receipt” to confirm receipt of this report.

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2021 and conducted by Evaluator Malia Thao

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210503141827

FACILITY NAME:	ROSEWOOD RETIREMENT COMMUNITY		FACILITY NUMBER:	150400536
ADMINISTRATOR:	BALABAN, ROCHELLE		FACILITY TYPE:	741
ADDRESS:	1301 NEW STINE ROAD		TELEPHONE:	(661) 834-0620
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93309
CAPACITY:	220	CENSUS: 151	DATE:	11/03/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Rochelle Balaban, Administrator Griscel Garcia, Memory Care Manager		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Multiple residents have stage 2 pressure injuries that are not being properly treated.
Facility staff do not ensure that residents have access to emergency call buttons.

INVESTIGATION FINDINGS:

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On 11/3/21 at 8:45 AM, Licensing Program Analyst (LPAs) Malia Thao and Lisa Salazar arrived unannounced to conduct a complaint investigation. LPA explained reason for inspection at front desk and was granted entry.
LPAs met with Griscel Garcia, Memory Care Manager and Administrator Rochelle Balaban.

During the course of the investigation, LPAs made observations, reviewed records, and interviewed staff and residents. This agency has investigated the complaint alleging multiple residents have Stage 2 pressure injuries that are not being properly treated. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted. A copy of this report will be emailed to the email on record with Read receipt to confirm receipt of this report.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 24-AS-20210503141827

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ROSEWOOD RETIREMENT COMMUNITY	FACILITY NUMBER: 150400536
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/04/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will submit proof of plan to start a weekly med cart audit for two months by the LVN to CCL by due date.
	8 9 10 11 12 13 14	LPAs found that the facility staff were not administering medication as prescribed. R1's medication Acetaminophen 325mg tablet was started on 10/29/21 as a routine medicine to be given two tablets by mouth every 8 hours for pain. Starting from 10/29/21 to today, only 9 doses have been administered, but 7 doses were remaining on the bubble pack card not given as prescribed. All doses for 10/29/21 through 10/31/21 were given. Doses for 11/1/21 through 11/3/21 AM dose were not given and still in the bubble pack card. This poses an immediate health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 11/17/2021 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (b) Assistance with instrumental activities of daily living in the combinations which meet the needs of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will submit proof of in-service training of the facility's TouchScreen charting tablet system for all staff providing care to residents to CCL by POC due date.
	8 9 10 11 12 13 14	LPA found that 3 out of 8 residents sampled showed Activities of Daily Living (ADL) logs did not match the residents basic services as shown on the residents' Physician's Report for Residential Care Facilities for the Elderly form LIC602A. This poses a potential health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

LIC9099 (FAS) - (06/04)

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