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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157206770
Report Date: 09/01/2023
Date Signed: 09/01/2023 03:45:08 PM

Substantiated


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
06/01/2023 and conducted by Evaluator Shawna Doucette
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230601095537
FACILITY NAME:POINTE AT SUMMIT HILLS, THEFACILITY NUMBER:
157206770
ADMINISTRATOR:BENNY FARILLASFACILITY TYPE:
740
ADDRESS:4501 UPLAND POINT DRIVETELEPHONE:
(661) 447-4800
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:102CENSUS: 72DATE:
09/01/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Perla PenaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not answer call bells timely due to lack of staffing
Staff leave residents in soiled diapers for an extended period of time due to lack of staffing
Staff would not call back authorized representative timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette and Miriam Flores conducted a visit to commence a complaint investigation and deliver findings. LPAs identified themselves and discussed the purpose of the visit and the elements of the allegations with Administrator, Perla Pena.

LPAs reviewed signal system logs, resident records, and conducted interviews.

Based on record review of signal system logs, LPA's found on 03/13/23 staff took over 6 hours to respond to R1's signal system call bell, on 03/16/23 staff did not to respond to R1's signal system call bell. This call was never acknowledged. LPA observed several other days where the reponse time is over 15 minutes or unanswered for the month of March 2023.
Based on records review of staff notes and interviews, R1 developed a rash due to being left soiled. On 04/14/23, staff notes state R1 and R1's husband notified staff during a 7:30 AM check that staff never came to change R1. On 4/19/23, staff notes state R1 developed a rash.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
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 6
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
06/01/2023 and conducted by Evaluator Shawna Doucette
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230601095537

FACILITY NAME:POINTE AT SUMMIT HILLS, THEFACILITY NUMBER:
157206770
ADMINISTRATOR:BENNY FARILLASFACILITY TYPE:
740
ADDRESS:4501 UPLAND POINT DRIVETELEPHONE:
(661) 447-4800
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:102CENSUS: 72DATE:
09/01/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Perla PenaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident didn't get showered timely due to lack of staffing
Resident left on floor for an extended period of time due to lack of staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette and Miriam Flores conducted a visit to commence a complaint investigation and deliver findings. LPAs identified themselves and discussed the purpose of the visit and the elements of the allegations with Administrator Perla Pena.

LPA interviewed staff and reviewed records.

During records review, staff did not document R1 had a fall on 4/16/23. After conducting staff interviews, staff could not recall a time where R1 was found on the floor.

During records review, staff documentation stated R1 refused showers regularly, however there were not daily notes to state how often R1 was offered a shower.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 24-AS-20230601095537
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: POINTE AT SUMMIT HILLS, THE
FACILITY NUMBER: 157206770
VISIT DATE: 09/01/2023
NARRATIVE
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Based on records review and staff interviews, it was undetermined whether or not R1 was left on the floor for an extended period of time. Based on interviews and records review undetermined whether or not resident was showered timely. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

A copy of this report was provided to Administrator.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 24-AS-20230601095537
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: POINTE AT SUMMIT HILLS, THE
FACILITY NUMBER: 157206770
VISIT DATE: 09/01/2023
NARRATIVE
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Based on records review and interviews, the LIC601 Identification and Emergency information form had an incorrect contact number for R1's responsible party. The form was not signed by R1's responsible party to ensure the information was correct. Based on interviews, the facility was not returning R1's responsible parties calls.

Based on interviews and records review the preponderance of evidence standard has been met; therefore, the above allegations are found to be Substantiated. Per California Code of Regulations, Title 22, deficiencies are being cited on the attached 9099-D.

An exit interview was conducted with Administrator Perla Pena and a copy of this report along with appeal rights and plans of correction were provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 24-AS-20230601095537
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: POINTE AT SUMMIT HILLS, THE
FACILITY NUMBER: 157206770
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the
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Plan of Correction: Licensee agrees to provide a written document stating the understanding of this regulation and the facilities policies on how this regulation will be met by POC due date.
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particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by R1's signal system call bell was not answered for about 6 hours on 3/13/23 and was not answered for about 10 hours on 03/16/23 which poses an immediate health, safety, and or personal rights risk to residents in care.
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Type A
09/15/2023
Section Cited
CCR
87625(b)(3)
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(b) In addition to Section 87611, General
87625 Managed Incontinence
Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Plan of Correction Licensee agrees to submit an incontinence plan to ensure this regulation is met by POC due date.
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This requirement was not met as evidenced by: Licensee did not enusre R1 was kept clean and dry per staff notes R1 was left wet all night on 04/14/23 and developed a rash on 4/19/23, which poses an immediate health, safety and personal rights risk to residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 24-AS-20230601095537
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: POINTE AT SUMMIT HILLS, THE
FACILITY NUMBER: 157206770
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
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 unusual weight gains or losses or deterioration of mental ability or a 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.
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Plan of Correction Licensee agrees to provide a written statement to licensing stating how this regulation will be met by POC due date.
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This requirement was not met as evidenced by: Licensee was not notifying R1's responsible party. Licensee did not have a correct phone number for R1's responible party (POA) and the LIC601 was not signed by the responsible party verifying the information was correct which poses a potential health safety and or personal rights risk to residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6