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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602925
Report Date: 04/15/2022
Date Signed: 04/15/2022 12:54:30 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
04/08/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220408164558
FACILITY NAME:ARBOR VISTAFACILITY NUMBER:
197602925
ADMINISTRATOR:COMMODORE, KIMFACILITY TYPE:
740
ADDRESS:811 E WASHINGTON BLVDTELEPHONE:
(626) 797-7296
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:69CENSUS: 49DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:KIm Commodore, AdministratorTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Reporting Requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit regarding the above allegation and delivered findings. The purpose of the visit was explained to Administrator Kim Commodore.

The investigation consisted of: On 4/12/22, LPA Galarza and Associate Governmental Program Analyst (AGPA) Michael Moriel conducted a physical plant tour, interviewed staff (S1-S5), and resident (R1). The following documents were obtained pertaining to R1: Face Sheet, Physician Report, ALW ISP, Appraisal Needs and Services Plan, incident reports, SNF & hospital discharge documents, LIC 500 Personnel Report, and resident roster. Durable Power of Attorney (DPOA) and Home Health staff were interviewed. During today's visit, residents (R2- R9) were interviewed.

See LIC 9099C for report continuation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
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 3
Control Number 28-AS-20220408164558
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: ARBOR VISTA
FACILITY NUMBER: 197602925
VISIT DATE: 04/15/2022
NARRATIVE
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Allegation: "Reporting Requirements". Resident (R1) returned to the facility from a Skilled Nursing Facility (SNF) on April 1, 2022. It is alleged that on 4/3/2022 the resident had an unwitnessed fall and was not sent to the hospital for further evaluation. Staff interviews indicated that if a resident falls and hurts themselves they are sent to the hospital for an evaluation. Administrator stated that sometimes residents refuse to go to the hospital, 911 Emergency is called anyway for an evaluation, and if the resident refuses they are not transported. Resident (R1's) Durable Power of Attorney stated incidents are reported in a timely manner. In regards to the incidents addressed on this complaint resident (R1) fell on 4/3/2022 but did not require medical treatment. An Incident report regarding resident (R1's) fall was completed, but not faxed to Licensing. A copy was obtained.

It is alleged resident (R1) sustained a minor toe injury because staff (S1) accidentally stepped on the resident's toe during bed transfer. The resident stated that it did not report the injury to any staff and they were made aware of the injury until 4/4/2022. Resident (R1) could not recall when the toe injury occurred. On 4/4/2022 a home health staff observed the toe injury and reported it to Administrator and staff (S1). Facility staff were not aware of the toe injury. As of 4/12/2022 an incident report had not been submitted to Community Care Licensing. LPA obtained a copy of the toe injury incident report during 4/15/2022 site visit, past the seven days Title 22 reporting requirement. Administrative Assistant staff acknowledged that it forgot to send the toe injury incident report.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is cited. See LIC 9099D.

Exit interview was conducted with Administrator Kim Commodore. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220408164558
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: ARBOR VISTA
FACILITY NUMBER: 197602925
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2022
Section Cited
CCR
87211(a)(1)
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Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below....

This requirement was not met evidenced by:
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Administrator agrees to conduct staff training on reporting requirements and send a copy of the inservice training log to LPA by POC due date
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Based on record review and interviews conducted the facility failed to report R1's fall incident dated 4/3/22, and toe injury dated 4/4/22. Staff acknowledged it forgot to submit the incident report. This poses a potential health and safety 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3