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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208915
Report Date: 05/22/2023
Date Signed: 05/22/2023 04:34:00 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
12/09/2022 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20221209104049
FACILITY NAME:PALMS AT SAN LAUREN, THEFACILITY NUMBER:
157208915
ADMINISTRATOR:RICE, DOUGLASFACILITY TYPE:
740
ADDRESS:5300 HAGEMAN RDTELEPHONE:
(661) 218-8333
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY:68CENSUS: 67DATE:
05/22/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Doug Rice, Administrator TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff didn't clean residents room timely
Staff did not meet the feeding needs of the resident
INVESTIGATION FINDINGS:
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On 05/22/23, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above allegations. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility.

During the investigation, LPA conducted interviews, reviewed medical records and telecommunications documentation. Telecommunication messages of date and time stamp videos show R1's room was not cleaned in a timely manner. LPA observed the LIC602 for Resident R1 dated 10/12/22, which states R1 does not have the capacity for self-care which includes ability to feed self. Interviews with staff state R1 is able to feed self and does not need assistance.

Based on the information received, the preponderance of evidence standard has been met, therefore, the above allegations are found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D. If not corrected, this poses a potential risk to residents in care.

(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
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 24-AS-20221209104049
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: PALMS AT SAN LAUREN, THE
FACILITY NUMBER: 157208915
VISIT DATE: 05/22/2023
NARRATIVE
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(Continued from 9099)

An exit interview and a plan of correction was developed by Administrator and reviewed with LPA. Plan of Correction is due by 06/12/23. A copy of this report was given to Administrator at the time of visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20221209104049
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: PALMS AT SAN LAUREN, THE
FACILITY NUMBER: 157208915
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2023
Section Cited
CCR
87470(a)(2)(A)
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(a) A licensee shall ensure that infection control practices are maintained as follows:(2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated or visibly soiled.
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Administrator will provide LPA with the cleaning checklist for each resident room in the Memory Care. Checklists will document and identify any immediate concerns to be corrected same day.
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This requirement was not met as evidenced by LPA's interviews and observation of text messages, that included the time and date of a visibly soiled bathroom and floor in Resident R1's room. This poses a potential threat to residents in care.
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Administrator will send proof of staff signatures evidencing rooms have been checked daily for the next 30 days. Proof of signed daily checklist will be sent to LPA by 06/25/23.
Type B
06/02/2023
Section Cited
CCR
87459(a)(6)(B)
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87459 Functional Capabilities (a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to: (6) Eating, including the need for:(B) Assistance from another person.
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Administrator will provide proof that care staff has been retrained on how to document resident's change of condition and reassessing resident needs after a change of condition occurs.
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This requirement was not met as evidenced by LPAs observation of LIC602, evidencing a change of condition. A functional assessment for feeding was not documented as completed by facility. This poses a potential 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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
12/09/2022 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20221209104049

FACILITY NAME:PALMS AT SAN LAUREN, THEFACILITY NUMBER:
157208915
ADMINISTRATOR:RICE, DOUGLASFACILITY TYPE:
740
ADDRESS:5300 HAGEMAN RDTELEPHONE:
(661) 218-8333
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY:68CENSUS: 67DATE:
05/22/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Doug Rice, Administrator TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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9
Insufficient staff to meet residents needs
Staff mismanaging residents medication
Staff did not safeguard resident's personal property
INVESTIGATION FINDINGS:
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On 05/22/23, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above allegations. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility.

During the investigation, LPA conducted interviews and records review. Staff schedules were observed to have approximately 4 caregivers, per shift, in the memory care unit that houses 24 residents. LPA conducted interviews and reviewed recent incident reports. Neither of which indicated the facility is short staffed.

LPA reviewed R1's records that includes a Hospice care plan and Centrally Stored Medical and Destruction Record. Hospice care plan and facility communication notes show facility staff is following the direct orders of the Hospice agency and physician.

(Continued on 9099-C)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20221209104049
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: PALMS AT SAN LAUREN, THE
FACILITY NUMBER: 157208915
VISIT DATE: 05/22/2023
NARRATIVE
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(Continued from 9099)

LPA observed a written personal property inventory form (LIC 621) for Resident R1, that was documented and signed at the time of admission. A copy was provided to R1's responsible party. The missing items mentioned in the allegation, were not observed to be documented on inventory the form. Interviews reveal items were purchased some time after admission and items were not requested to be added to the inventory form.

Based on the information received, we have found that the complaint allegations are Unfounded, meaning that the allegations are without reasonable basis, therefore, we have dismissed the above complaint. No deficiencies cited. Exit interview conducted. A copy of this report was provided to Administrator
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5