157208915-6-8-2023-24-AS-SPIY-CTDNTZ-20230703104530

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157208915
Report Date: 06/08/2023
Date Signed: 06/08/2023 05:08:33 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
03/21/2023 and conducted by Evaluator Darius Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230321111428

FACILITY NAME:	PALMS AT SAN LAUREN, THE		FACILITY NUMBER:	157208915
ADMINISTRATOR:	RICE, DOUGLAS		FACILITY TYPE:	740
ADDRESS:	5300 HAGEMAN RD		TELEPHONE:	(661) 218-8333
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93308
CAPACITY:	68	CENSUS: 65	DATE:	06/08/2023
		UNANNOUNCED	TIME BEGAN:	08:39 AM
MET WITH:	Administrator, Douglas Rice		TIME COMPLETED:	11:02 AM

ALLEGATION(S):

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Staff are not answering call bells timely

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Darius Williams and LPA Shawna Doucette conducted a follow up complaint visit. LPA's met with Administrator, Douglas Rice and discussed the purpose of the visit.

LPA Williams interviewed witnesses, the Administrator, and reviewed records.

On 3/28/2023, LPA Williams pulled a chord in room 206, which notifies the facility signal system. Staff took approximately 4 minutes and 32 seconds to respond, taken via LPA Williams phone timer.

However, according to Kern Fire Department (KFD) record, on 3/29/2023 at approximately 11:02 pm, KFD responded to a residents peronsal pendant. When KFD arrived, no staff could be located in assisted living (addressed on complaint control # 24 - AS - 20230330093440).

*Continued on LIC 9099-C*

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

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 24-AS-20230321111428

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: 06/08/2023

NARRATIVE

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KFD pulled a chord in a residents room to notify the facility signal system. Staff 1 arrived to the front desk approximately after 30 minutes the chord was pulled and informed KFD that they had to leave and drop their child off.

According to, Witness 1, Witness 2, and Resident 2 interviews, all three reported they have experienced times when staff respond in under 10 minutes and times,it has taken staff longer than 20 minutes to respond, to the pull chord.

LPA Doucette requested signal system call logs between 3/15/2023 - 3/31/2023, which were not provided.

Based on LPA's, record review and interviews, the preponderance of evidence standard has been met, therefore the allegation, staff are not answering call bells timely, is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, 87411(a) is being cited on the attached LIC 9099-D page.

A plan of correction was reviewed and discussed with the Administrator.

An exit interview was conducted and a copy of this report and appeal rights will be provided via e-mail.

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230321111428

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: 06/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/16/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ... This requirement was not me evident by:	1 2 3 4 5 6 7	Administrator agreed to provide copies of the facility signal system, to the Department between the dates of 6/9/2023 through 6/15/2023, for review. Seven records are to be provided to the Department by POC due date of 6/16/2023.
	8 9 10 11 12 13 14	Based on LPA's interviews and record reviews, on 3/29/2023, the Licensee did not ensure staff were present, for approximately 30 minutes, to respond to the facilities signall system, which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC9099 (FAS) - (06/04)

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