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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157206770
Report Date: 09/08/2023
Date Signed: 09/08/2023 02:57:56 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
06/27/2023 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20230627144600
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: 62DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Administrator Perla PenaTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident suffered from multiple falls causing injury due to lack of staff supervision.
Staff did not ensure that resident's room was clean and did not ensure that resident's room was free from clutter.
Staff did not provide adequate laundry services for resident in care.
Staff did not respond to resident's requests for assistance in a timely manner.
Staff did not administer medication(s) to resident as necessary.
Staff did not ensure that resident's medication prescriptions were refilled.
Staff did not maintain accurate medical records regarding resident in care.
Staff did not provide documents to resident's Responsible Party in a timely manner.
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.

The Department has investigated the allegation: Neglect/ Lack of Care and Supervision Resident suffered from multiple falls causing injury due to lack of staff supervision. Based on medical record review, facility documents, interviews, and photos, R1 suffered from multiple falls causing several injuries, which resulted in hospitalization.

Based on interviews and photos, staff did not ensure resident’s room was clean and did not ensure resident’s room was free from clutter. Residents room photos showed items scattered all over the floors and counters in the residents living quarters, obstructing passageways. Resident bathroom counters were dirty.

Based on interviews and photos, staff did not provide adequate laundry services for resident in care. LPA's observed in the photo laundry overflowing onto the floor from the hamper and laundry scattered throughout residents room blocking passage ways.



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: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
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 9
Control Number 24-AS-20230627144600
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: 09/08/2023
NARRATIVE
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Based on records review of signal system, records showed facility did not respond to resident's requests for assistance in a timely manner. Signal system records show for R1's room the chord was pulled on 4-26-23 at 7:22 PM and answered at 7:38 PM. On 4-21-23 records show R1 pulled the chord at 8:28 AM and staff did not respond until 9:01 AM. After conducting interviews, at the time staff were trained to have a response time not over 10 minutes.

Based on record review, Staff did not administer medication(s) to resident as necessary. After review of MARS log R1 missed several medications from January 2029 to June 2023.

Based on record review, Staff did not ensure that resident's medication prescriptions were refilled. According to MARS log and staff notes, R1 received this medication in January 2023 and did not receive this medication in February 2023. This medication was not refilled until March 2023.

Based on record review staff did not maintain accurate medical records regarding resident in care. After reviewing Centrally Stored log for R1's medications it was found to be incomplete.

Based on interviews and documents, Staff did not provide documents to resident's Responsible Party in a timely manner. An email was sent to facility staff on May 12, 2023 requesting a copy of MARS log with no response from the facility.

Based on the Departments facility record review, photos, medical records review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Article 8, and Health and Safety are being cited on the attached LIC 9099D.

An immediate Civil Penalty is being issued. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report, if any.

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

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 24-AS-20230627144600
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: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2023
Section Cited
HSC
1569.49(c)(1)
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1569.49 Civil penalties; regulations setting forth appeal procedures for deficiencies (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations: (1) Any violation that the department determines resulted in the injury or illness of a resident.
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Plan of Correction POC

Licensee agrees to provide a written statement on the understanding of this regulation by POC due date.

Civil Penalties were issued.
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This requirement was not met as evidenced by: Licensee did not place fall prevention tecniques by not keeping pathways free of obstruction and did not have sufficient staffing to meet residents needs, resulting in R1 falling several times causing a broken bone, a fractured skull and brain hemorage, which resulted in several hospitalizations which is an immediate health safety and/or personal rights risk to residents in care.
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Type A
09/08/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Plan of Correction POC Licensee agrees to send photos of 5 rooms by POC due date.





Cvil Penalty issued. Repeat violation.
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This requirement was not met as evidenced by: Licensee did not keep R1's room clean and free of obstruction, which poses an immediate 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: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 24-AS-20230627144600
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: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2023
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 particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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Plan of Correction POC Licensee agrees to submit staffing shedule for the month that reflects actual staff that worked by POC due date.





Cvil Penalty issued. Repeat Violation.
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This requirement was not met as evidenced by: Licensee staff did not respond to pull chord for R1 in a timely manner on 4/21/23 and 4/26/23, which was over 30 minutes, which poses an immediate health, safety, and/or personal rights risk to residents in care.
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Type A
09/29/2023
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.
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Plan of Correction POC Licensee agrees to conduct training for medication techinicians that are not new hires by POC due date.




Cvil Penalty issued. Repeat violation
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This requirement was not met as evidenced by: Licensee did not administer several of R1's medications on 04/08/23, 04/09/23 ect which poses an immdiate 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: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 24-AS-20230627144600
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: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2023
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Plan of Correction POC
Licensee agrees to submit facility policy on reordering medications for residents in care by POC due date.



Civil Penalty Issued Repeat Violation
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This requirement was not met as evidenced by: Licensee did not refill R1's blood pressure medication for the month of February 2023. R1 received the medication in January 2023 and resumed in March 2023 which poses an immediate health, safety and or personal rights risk to residents in care.
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Type B
09/08/2023
Section Cited
CCR
87307(a)(3)F)
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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:
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Plan of Correction POC Licensee agrees to to submit laundry schedule for residents in care and submit a statement on how residents needs will be met by POC due date.
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(F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement was not met as evidenced by: Licensee did not ensure basic laundry service was provided to R1 per interviews and photos which show laundry overflowing onto the floor and all over the floor of R1's room 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: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 24-AS-20230627144600
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: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
87506(b)(14)
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87506 Resident Records
(b) Each resident’s record shall contain at least the following information: (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by:
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Plans of Correction POC

Licensee agrees to submit 5 resident centrally stored log for the month September 2023 by POC due date.
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Licensee did not have a current centrally stored log or list of current medications for R1 which poses a potential health safety and or personal rights risk to residents in care.
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Type B
09/29/2023
Section Cited
CCR
87468.1(a)(9)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately.
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Plan of correction POC Licensee agrees provide a written statement of policies for providing resident records to Responsible representitive by POC due date.
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This requirement was not met as evidenced by Licensee did not provide requested documents to R1's responsible representative
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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: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 9
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
06/27/2023 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20230627144600

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: 62DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Administrator Perla PenaTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident developed a pressure injury while in care due to lack of staff supervision.
Staff did not prevent resident from using unsafe bedding materials.
Staff did not store resident's medication(s) properly
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.

Based on records review, Although R1 may have developed a pressure injury while in care, facility staff sought medical attention immediately once it was observed on 6/3/23.

Based on interviews, it is undetermined whether or not R1's bedding materials (heating blanket) was a safety issue. R1 no longer resides in the facility.

Based on interviews and records review, it is undermined whether or not R1's medications were stored properly. R1's LIC602 physicians report states R1 can leave the facility unsupervised. R1 was purchasing over the counter medications while on outings and bringing the medications back to R1's room. Although over the counter medications were found in R1's room, facility immediately removed medications once observed due LIC602 starting R1 needs assistance with medications.

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: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 24-AS-20230627144600
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: 09/08/2023
NARRATIVE
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Based on interviews and records review, it is undermined whether or not R1's medications were stored properly. R1's LIC602 physicians report states R1 can leave the facility unsupervised. After conducting interviews, it was stated R1 was purchasing over the counter medications while on outings and bringing the medications back to R1's room. Although over the counter medications were found in R1's room, facility immediately removed medications once observed due LIC602 starting R1 needs assistance with medications.
The Department has investigated the above allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.


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

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 9
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
06/27/2023 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20230627144600

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: 62DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Administrator Perla PenaTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident wandered from the facility due to lack of staff supervision.
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.

Based on interviews, it was found R1 never wandered from the facility. There was only a concern R1 would leave the facility with another resident who is a friend of R1.

This Department has investigated the complaint alleging, Resident wandered from the facility due to lack of staff supervision. We have found that the complaint was UNFOUNDED, which means the the allegation could not have happened, and/or is without reasonable basis, therefore we have dismissed the complaint.

A exit interview was conducted with Administrator Perla Pena and a copy of this report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 9 of 9