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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209146
Report Date: 07/05/2023
Date Signed: 07/05/2023 01:06:11 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
03/24/2023 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20230324154345
FACILITY NAME:QUALITY CARE ASSISTED LIVINGFACILITY NUMBER:
157209146
ADMINISTRATOR:ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:2607 MT. VERNON AVENUETELEPHONE:
(661) 871-8133
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:54CENSUS: 45DATE:
07/05/2023
UNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Staff Baula Maribel BrizuelaTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Neglect/ Lack of Care and Supervision resulting in resident being diagnosed with severe dehydration and staff not seeking medical attention for resident in a timely manner.
Staff are not properly addressing scabies in the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette conducted an unannounced complaint visit to deliver findings. LPA met with Staff Baula Maribel Brizuela and discussed the purpose of the visit. Administrator was not available for the visit. LPA spoke with Staff Oscar Chavez via telephone who assisted with the visit.

The Department has investigated the allegationa: Neglect/ Lack of Care and Supervision resulting in resident being diagnosed with severe dehydration and staff not seeking medical attention for resident in a timely manner and Staff are not properly addressing scabies in the facility.

According to interviews and records review the Department found, R1 did not recieve medical attention in a timely manner resulting in severe dehydration causing damage to R1's organs and causing other serious medical condtions due to neglect/lack of care and supervision, requiring R1 to be hospitalized. Staff did not seek medical attention for over a month.

*Continued on 9099C
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: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
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 3
Control Number 24-AS-20230324154345
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: QUALITY CARE ASSISTED LIVING
FACILITY NUMBER: 157209146
VISIT DATE: 07/05/2023
NARRATIVE
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According to interviews and records review the Department found, staff are not properly addressing scabies in the facility by not properly following the physicians medication orders for R1.

Based on the Departments record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Article 8, 87465 (a)(4) and Health and Safety Code 1569.49(c)(1) is being cited on the attached LIC 9099D.

An immediate Civil Penalty is being assessed. 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.

The Department found additional deficiencies during the course of the investigation, which will be addressed and cited on a separate 809 and 809D.

An exit interview was conducted, a copy of this report, plans of correction, and appeal rights were provided.

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

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20230324154345
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: QUALITY CARE ASSISTED LIVING
FACILITY NUMBER: 157209146
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2023
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
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Plan of Correction POC Licensee agrees to submit a written statement on how the facility will meet this regulation in the future.

Immediate $500 Civil Penalty was issued
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citation for any of the following serious violations: (1) Any violation that the department determines resulted in the injury or illness of a resident. This was not met as evidenced by: Licensee did not seek timely medical attention for R1, resulting in a hospitalization with additional medical issues due to neglect, which poses an immediate health, safety, and/or personal rights risk to residents in care.
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Type A
07/06/2023
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
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Plan of Correction POC Licenee agrees to conduct a staff training on applying medication and following physicians orders by POC due date 07/14/23
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compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This was not met as evidenced by: Licensee was not following physician orders when administering R1's medication, 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: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3