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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600281
Report Date: 10/27/2020
Date Signed: 10/27/2020 04:21:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GRACE MANORFACILITY NUMBER:
197600281
ADMINISTRATOR:COSTALES, GRACE A.FACILITY TYPE:
740
ADDRESS:17100 CALAHAN ST.TELEPHONE:
(818) 993-9354
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: DATE:
10/27/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:26 PM
MET WITH:Grace CostalesTIME COMPLETED:
04:30 PM
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Approved for Issuance (809) – Grace Manor (#197600281)
On 10/27/2020, Licensing Program Analyst (LPA), Alex Pitz met with (facility representative), for a case management visit to follow up on a substantiated allegation that the facility failed to seek timely medical care for a resident (R1).

On June 23, 2017, the Department concluded a complaint investigation which alleged the facility failed to provide appropriate care for R1 which resulted in pressure injuries. According to the National Pressure Ulcer Advisory Panel, a pressure injury (ulcer) is a ‘’localized injury to the skin and/or underlying tissue usually over a bony prominence, primarily as a result of pressure, or pressure in combination with shear and/or friction.”

The allegation was substantiated and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87466 Observation of the Resident, which states that “the licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.” The licensee was further cited for violating CCR Title 22 § 87615 (a)(1) Prohibited

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRACE MANOR
FACILITY NUMBER: 197600281
VISIT DATE: 10/27/2020
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Health Conditions, which states in part that “persons who require health services 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: (1) Stage 3 and 4 pressure sores (dermal ulcers)”.

The investigation consisted of interviews of facility personnel and residents. R1 was not interviewed due to their inability to verbally articulate. Copies of supportive medical records from the hospital were obtained and reviewed.

The investigation revealed that R1 was admitted to the facility on May 4, 2013. R1’s Physician’s Report dated June 14, 2016 did not document any history of skin condition or breakdown. On November 24, 2016, the administrator (S1) stated during interviews that she was informed by a staff member (S2) that R1 did not look well and had lost their appetite. Emergency services (9-1-1) was called due to R1 not looking well and a loss of appetite. An ambulance transported R1 to a general acute care hospital with an admitting diagnosis of septic shock due to a urinary tract infection (UTI), aspiration pneumonia, and shortness of breath. According to the Mayo Clinic, sepsis shock is a widespread infection causing failure and dangerously low blood pressure. Septic is a potentially life-threatening condition caused by a serve localized or system-wide infection that requires immediate medical care attention.

Hospital records for November 24, 2016 also indicate that R1 had the following pressure injuries:

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRACE MANOR
FACILITY NUMBER: 197600281
VISIT DATE: 10/27/2020
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1. A left heel Stage 4 measuring 2 cm x 1.8 cm x 0.1 cm
2. A right heel unstageable measuring 3.1 cm x 2.1cm x 0.1 cm
3. A left hip Stage 3 measuring 0.4 cm x 1.8cm x 0.1 cm

It is unknown when R1’s pressure injuries developed.

During an interview with the administrator (S1) of the facility, the S1 stated that R1’s assigned caregiver (S2) informed the S1 about R1’s loss of appetite on November 24, 2016. The S1 also stated that S1 was unaware of R1’s pressure injuries. S1 stated that after R1 was hospitalized, S2 admitted that S2 had failed to inform S1 of R1’s pressure injuries. S1, the administrator terminated S2 immediately after hearing S2’s confession. The Department was unable to interview S2, because S2 allegedly left the country.

R1 was discharged from the hospital on December 5, 2016 to board and care in Northridge with hospice care.

Based on observation, interview, and record review, the licensee failed to regularly observe changes in R1’s physical state. In addition, the licensee failed to seek timely medical care for R1 which led to R1 being hospitalized with 3 pressure injuries to include: one Stage 3, one Stage 4, and one unstageable pressure injuries.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRACE MANOR
FACILITY NUMBER: 197600281
VISIT DATE: 10/27/2020
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 The licensee’s failure to seek timely medical care caused R1 to suffer a serious bodily injury.

At the time of the complaint visit, an immediate civil penalty of $150 was issued. The licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institution Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, 10/27/20, the Department is issuing a civil penalty per Health and Safety Code §1569.49 in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $150 was previously issued on June 23, 2017, the amount of the civil penalty issued is reduced to $9,850. A copy of the LIC 421D was given to the (facility representative) and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. (facility representative) signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4