191591883-8-31-2022-28-AS-MVAO-CJ9T53-20220914142451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191591883
Report Date: 08/31/2022
Date Signed: 08/31/2022 01:44:35 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, 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
08/26/2020 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200826134136

FACILITY NAME:	TORY CARE HOME		FACILITY NUMBER:	191591883
ADMINISTRATOR:	DANILO RAMOS		FACILITY TYPE:	740
ADDRESS:	2721 TORY ST.		TELEPHONE:	(626) 965-4899
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91792
CAPACITY:	5	CENSUS: 4	DATE:	08/31/2022
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Danilo Ramos		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Severe neglect resulting in resident developing multiple pressure injuries.
Staff administered expired medication to resident.
Staff did not seek medical attention for resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Galarza and Yang conducted a subsequent complaint visit to deliver findings on the above allegations investigated by Department of Social Services Investigations Branch (IB) Investigator Olivia Spindola. The purpose of the visit was discussed with Licensee/Administrator Danilo Ramos.

The investigation consisted of: Due to the COVID-19 pandemic a virtual physical plant inspection was conducted on 8/27/2020. No interviews were conducted. Resident (R1's) documents [Identification and Emergency Information (Face Sheet), Physician Report, Preplacement Appraisal Information, Resident Appraisal/ Re-Appraisals, Appraisal/Needs and Services Plan, IPP, Medication Administration Records (MAR's) for months June 2020- August 2020, Medical Doctor Visit Notes (July 2020 - August 2020), Caregiver Notes (July 2020- August 2020), Admission Agreement, Hospital ER discharge documents (August 18, 2020), Incident reports], LIC 500 Personnel Report, and resident roster were obtained. Regional Center Quality Assurance staff was interviewed on 8/25/2020. IB invvestigator interviewed staff (S1 & S2), residents (R2-R5), Regional Center Service Coordinator, and obtained R1's medical records and pictures of multiple pressure injuries.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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 28-AS-20200826134136

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: TORY CARE HOME	FACILITY NUMBER: 191591883
	VISIT DATE: 08/31/2022

NARRATIVE

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Allegation: Severe neglect resulting in resident developing multiple pressure injuries. It is alleged that resident (R1) developed three (3) pressure injuries, of which two (2) of the pressure injuries were unstageable, which meant they were presumably a stage 3 or higher, and thereby a prohibited condition for an individual not enrolled in hospice that lives at an Residential Care For the Elderly (RCFE) facility. On July 31, 2020, Licensee/Administrator noticed that resident (R1) developed pressure injuries to the inner right knee and lower back. Resident (R1) was seen for pressure injuries by Primary Care Physician (PCP) until August 12, 2020. On August 13, 2020, Alsa Home Health was certified to receive home health care for "Stage 2 Pressure Ulcer or right lower back & Unstageable Ulcer of right medial knee." On August 21, 2020, home health treated an additional stage 3 sacrococcyx, right knee, and right ischial. By August 23, 2020 the two of the three wounds were stage 3, and one wound was unstageable. On August 25, R1 was transferred to skilled nursing facility. By August 26, 2020 right knee wound and sacrococcyx were unstageable, and right ischial wound was stage 3.

There is circumstantial evidence substantiating neglect of care resulting in multiple pressure injuries. Medical records indicate resident (R1) had at least one (1) unstageable pressure injury two (2) weeks before medical care was received. Licensee’s admitted they treated the pressure injuries for at least two weeks before medical care was sought. Pictures were obtained.

Allegation: Staff administered expired medication to resident. It is alleged that Licensee/Administrator Danilo Ramos noticed skin breakdown in resident (R1) the last week of July 2020; 2 weeks before the resident received medical care. Instead of seeking medical care he applied expired ointment medication from R1's 2018 pressure injuries. Administrator acknowledge using expired/discontinued medication to treat the pressure injuries. Staff (S2) stated Santyl ointment was applied. Facility staff did not contact R1's Primary Care Physician to obtain a physician order to to treat the pressure injuries.

See LIC 9099C for report continuation

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20200826134136

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: TORY CARE HOME	FACILITY NUMBER: 191591883
	VISIT DATE: 08/31/2022

NARRATIVE

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Allegation: Staff did not seek medical attention for resident in a timely manner. Based on interviews conducted and record review the investigation revealed that at the end of July 2020 the licensee's began treating R1's pressure injuries. Staff (S2) scheduled an appointment with R1's Primary Care Physician until August 7, 2020. However, due to the COVID-19 pandemic the doctor's office cancelled and rescheduled the appointment for August 12, 2020. Home health care order was effective dates 8/13/2020- 10/11/2020. The 1st home health visit was conducted on August 15, 2020. On August 18, 2020, licensee notified the San Gabriel/Pomona Regional Center (SGPRC) that R1 began receiving home health. Photographs were reviewed by a Regional Center nurse, and Licensee was directed to take R1 to the hospital emergency room for wound and proper staging. On August 19, 2020 Licensee took R1 to Inter-Community Hospital Covina to get pressure injuries treated as they were getting worse. On August 25, 2020, R1's Primary Care Physician ordered resident transferred to an inpatient skilled nursing facility for an extended period. Principal diagnosis was stage 4 pressure injury in right knee, stage 2 right hip pressure injury, and stage 2 left heel pressure injury. Resident (R1) had been residing at the facility with two unstageable pressure injuries since at least 8/12/2020 - 8/19/2020. On August 27, 2020, the San Gabriel/Pomona Regional Center met with Licensee to discuss and develop a Corrective Action Plan (CAP) regarding all the above allegations. Sanctions to the facility were imposed. Based on the investigation there is evidence to corroborate the allegation.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D)

An exit interview was conducted with Licensee/Administrator Danilo Ramos. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20200826134136

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: TORY CARE HOME	FACILITY NUMBER: 191591883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/01/2022 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement was not met evidenced by:	1 2 3 4 5 6 7	Licensee agress to read regulation 87615 and train all staff. Submit by tomorrow a written statement explaining how you complied and proof of staff training.
	8 9 10 11 12 13 14	Based on record review and interviews conducted, resident (R1) developed three (3) pressure injuries, of which two were stage 3, and one wound was unstageable while residing in the facility. This poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
Type A 09/01/2022 Section Cited CCR 87465(e)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician... This requirement was not met evidenced by:	1 2 3 4 5 6 7	Licensee shall obtain training for all staff by a pharmacy or registered nurse. Submit proof of staff training materials (topic), sign in sheet, and signature from trainer.
	8 9 10 11 12 13 14	Based on record review and interviews conducted staff applied on R1 expired Santyl ointment medication from R1's 2018 pressure injuries onto R1's skin breakdown areas. This poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20200826134136

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: TORY CARE HOME	FACILITY NUMBER: 191591883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/31/2022 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility...The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met evidenced by:	1 2 3 4 5 6 7	Licensee agrees to submit a written plan addressing pressure injury prevention and treatment. Submit: 1. A plan that includes whole body checks, documentation, arranging for client's medical care. 2. Proof of staff training
	8 9 10 11 12 13 14	Based on record review and interviews conducted, the Licensee/Administrator did not seek medical care for resident (R1) to treat pressure injuries, until approximately 2 weeks after noticing skin breakdown, which resulted in pressure injury staging to advance into prohibited health conditions. This poses an immediate health and safety risk.	8 9 10 11 12 13 14
Type A 09/01/2022 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning .....the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	Licensee shall read Title 22 regulation and review Plan of Operation and develop a written plan acknowledging understanding of regulation requirements. Provide training to all staff and submit a written statement addressing this regulation.
	8 9 10 11 12 13 14	This requirement was not met evidenced by: Based on interviews and record review, the licensee failed to contact R1's Primary Care Physician when pressure injuries developed. R1 saw a physician until 2 weeks later; which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

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