191290642-8-15-2023-31-AS-ACAN-CULSN2-20230811140049

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191290642
Report Date: 08/11/2023
Date Signed: 08/15/2023 09:55:22 AM

Document Has Been Signed on 08/15/2023 09:55 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/14/2023 04:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

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Deficiency Noted: Facility failed to seek timely medical attention for resident.

LPA Ashley Calderon conducted a case management visit on 8/11/23 regarding staff observing resident #1 to have sustained bruising to chest area on 11/24/22 and 11/25/22.

During today's visit LPA Calderon interviewed current Administrator Celia Garcia, Assistant Administrator Nilda Mercado, Staff #5, and Staff # 11. LPA attempt telephone interview S7 and LPA spoke with Office Manager Cynthia Valdez via telephone. LPA collected staff communication log regarding resident #1 (R1).

During the investigation conducted with Investigator Douglas Real, Staff #7 (S7) was working the night shift on 11/24/23 and at around 11:30 PM, S7 observed that resident #1 (R1) who is diagnosed with dementia per medical assessment dated 11/24/22, to have a half dollar sized purple mark or bruise located around the center of resident #1 chest area. On 11/25/22, at around 7AM, R1 visitor along with staff # 5 (S5) observed resident #1 had a large area of bruising to R1's right side chest/breast area. Resident #1 was unable to inform staff how the bruising occurred and there was no evidence to indicate resident #1 fell, sustained injury or that staff or anyone harmed R1. Investigator Real interviewed Administrator Celia Garcia regarding R1 bruising which revealed that Administrator Garcia was employed in the facility, however, Administrator Garcia was not the facility Administrator at the time of the incident. Administrator Garcia did not know why R1 was not taken for medical treatment until 1PM on 11/25/22. Investigator Reals interviewed Office Manager Cynthia Valdez regarding resident #1 bruising revealed that Administrator Garcia and Office Manager Valdez reported that on 11/25/22 at 7AM being informed by R1’s family member that R1 sustained bruising to chest area. Office Manager Valdez did not know why resident #1 was not taken for medical attention until 1PM on 11/25/22.

Continuation 809-C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
	VISIT DATE: 08/11/2023

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Therefore, the investigation revealed that facility staff were aware resident #1 had bruising to the chest area on 11/24/22 during the night shift and staff were made aware of resident #1 injury on 11/25/22 at 7AM by resident #1 visitor. Despite staff being aware of resident #1 bruising at 7AM on 11/25/22, staff failed to obtain timely medical attention for resident #1 until 1 PM the same day, which was six hours later, when resident #1 was transported to a hospital via ambulance for medical treatment.

Therefore, the investigation revealed Staff failed to meet residents’ health care needs by not obtaining medical attention for resident #1 until 6 hours after staff being aware or resident #1 bruising.

Deficiencies were issued on today’s visit per Title 22 Division 6 Chapter 8. An exit interview was conducted with Administrator Celia Garcia and a copy of todays reports and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/11/2023 02:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: LEISURE VALE RETIREMENT HOTEL	FACILITY NUMBER: 191290642
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 09/01/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident. The licensee shall ensure...observed for changes in physical, mental, ...functioning .... appropriate assistance is provided...physical health condition are observed, the licensee shall ensure that such changes are documented/attn to resident's Dr / responsible person, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agrees to: 1) Review the policy for monitoring residents and will provide a in-service training regarding Regulation 87466 to front office personnel's. Will submit training sign-in sheet to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted, record review and observations conducted by LPA Calderon and IB Investigator Real, the facility did not take action to notify resident's physician and failed to provide care in a timely manner	8 9 10 11 12 13 14	2) Develop and Submit facility protocol, which details how care staff are instructed to identify , document and report any changes in resident condition.
	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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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