191501662-3-6-2023-28-AS-RORN-CR9ULD-20230426154034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191501662
Report Date: 03/06/2023
Date Signed: 03/06/2023 03:19:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2023 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230301112457

FACILITY NAME:	BRETHREN HILLCREST HOMES		FACILITY NUMBER:	191501662
ADMINISTRATOR:	KEITH KASIN		FACILITY TYPE:	741
ADDRESS:	2705 MOUNTAIN VIEW DRIVE		TELEPHONE:	(909) 593-4917
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	574	CENSUS: 377	DATE:	03/06/2023
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Keith Kasin- Executive Director & Desiree Eudave- Director of Resident Care		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff did not adequately supervise resident resulting in resident being found outside with a head injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial visit to the facility for the purpose of investigating the above-mentioned allegation. LPA Maldonado met with Keith Kasin- Executive Director and Desiree Eudave- Director of Resident Care and explained the purpose for the visit.

During the visit, LPA obtained a copy of the resident and staff roster for the memory care unit, conducted a tour of the memory care unit (physical plant), and obtained the following records for Resident# 1 (R1): Facesheet, Physician's Report, Pre-Placement Appraisal, Current Appraisal, LIC624-Incident report for 2/28/23, internal incident report for 2/28/23, Hospital Discharge documents, Plan of Operations- Absentee Notification Plan for Missing Residents, and current care plan. LPA also conducted interviews with Staff# 1 (S1) in person, Staff# 2-5 (S2-S5) telephonically, due to staff not present in the facility at the time of the visit, and attempted to interview R1.
The investigation revealed the following:
(Report Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

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 28-AS-20230301112457

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRETHREN HILLCREST HOMES	FACILITY NUMBER: 191501662
	VISIT DATE: 03/06/2023

NARRATIVE

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Regarding allegation: Facility staff did not adequately supervise resident resulting in resident being found outside with a head injury.
It is alleged that R1 was found outside of the facility with blunt head injury while it was cold and raining, and is unknown for how long R1 was left outside for. LPA conducted a tour of the facility memory care unit (MCU) with the assistance of Keith and Desiree. LPA observed the MCU to have one central entry point that is locked and could only be opened by entering a code on a keypad, located to the left of the door. R1's room was inspected. The room is a shared bedroom and has a door that leads outdoors to the locked patio area, still located within the MCU. The door was equipped with an auditory device and was operational at the time of the visit. During interviews conducted, (5) of (5) staff confirmed R1 had a fall on 2/28/23, that resulted in a head injury; however, all residents in the MCU receive visual checks every one hour, to ensure they are still within the parameters. S2 and S3 were present when the incident occured. (1) of (2) staff state the auditory device in R1's room was not operating when the incident occurred, while the other staff could not recall if the auditory device was operating. Per S3, at about 2:00AM, R1 was checked on and was in bed. At about 3:00AM, S3 returned to begin checking on the residents and arrived at R1's room at about 3:45AM. Upon arrival at R1's room, S3 noted that R1 was not in bed and informed S2. Both staff searched for R1 throughout the MCU and did not find R1. S3 then walked out of R1's bedroom door toward the MCU patio, about 15 feet away, and found R1 on the floor with bruising and a laceration above the eye - still within the MCU's parameters. R1 never left the MCU. S2 states to have followed behind S3. So, when S3 found R1, S2 assisted S3 to check on R1 and S3 went to go call the facility nurse and proceeded to call 911. (3) of (5) staff stated they did not notice a change in condition or behavior from R1 in the events leading to R1's fall, nor did R1 express a desire to leave the facility at any time. (2) of (5) staff state they were informed at shift change that R1 appeared to be more agitated and confused than usual. After review of R1's Physician's report dated: 08/30/22, R1 is unable to leave the facility unassisted due to cognitive impairment, does not have wandering behavior, and does not have sundowning behavior. Per R1's Pre-Placement appraisal and current appraisal, R1 is able to ambulate independently without assistance of a device.Per hospital discharge documents, R1 was discharged to facility skilled nursing to receive wound treatment on eye laceration. LPA attempted to interview R1 to obtain details of the incident; However, due to R1's cognitive impairment, R1 could not recall the incident occurring.

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 complaint investigation of the allegations are Unsubstantiated.

Per California Code of Regulations, Title 22 and Health and Safety Code, no deficiencies were cited.
An exit interview was conducted and a copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC9099 (FAS) - (06/04)

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