197602925-9-29-2022-28-AS-RORN-CJXSBW-20221006134437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602925
Report Date: 09/29/2022
Date Signed: 09/29/2022 03:36:53 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
09/16/2021 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210916162357

FACILITY NAME:	ARBOR VISTA		FACILITY NUMBER:	197602925
ADMINISTRATOR:	COMMODORE, KIM		FACILITY TYPE:	740
ADDRESS:	811 E WASHINGTON BLVD		TELEPHONE:	(626) 797-7296
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	69	CENSUS: 48	DATE:	09/29/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Administrator Kim Commodore		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility did not ensure that resident was adequately fed.

Facility staff did not notify resident’s representative of a change in the resident’s condition in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Administrator (A1: Kim Commodore). LPA/RA spoke to A1 prior to entering the facility to conduct a risk assessment. A1 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms.

The purpose of today’s visit is to conduct a subsequent visit and to deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day visit was conducted by LPA Angelica Rea on 09/20/21. LPA/RA Ceniceros re-interviewed (between 1:00 p.m. - 1:30 p.m.) two (2) staff members (A1 & S1). LPA/RA did not interview (former) Resident #1; as the resident did not return to the facility following hospitalization on 09/13/21. LPA/RA reviewed (between 1:45: p.m. – 2:15 p.m. the requested documents: Emergency I.D. and Information, Physician’s Report, Resident Appraisal, Functional Capability Assessment, Appraisal Needs and Services Plan, and Pre-hospital Care Report for Resident #1 (R1); including police reporting of local law enforcement, Unusual Incident/Injury Report, Facility Staff and Residents rosters, and weekly menu.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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-20210916162357

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: 09/29/2022

NARRATIVE

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Regarding Allegation #1: this investigation revealed a review of R1's "Physician Report" (dated 11/10/19) documented under "Mental Condition" Able to communicate Needs: Yes; under "Capacity for Self Care" Resident able to feed self: Yes. A review of the "Resident Appraisal" (dated 01/23/20) documented under the "Services Needed" Help with eating (need for adaptive devices or assistance from another person): No. A review of R1's "Functional Capability Assessment" (dated 01/23/20) documented under "Eating" that the resident feeds self completely and under "Communication" that the resident expresses self verbally. A review of R1's "Appraisal Needs and Services Plan" (dated 01/23/20) documented that facility staff will monitor the resident to ensure that the resident is using their independent skills. A review of the facility's weekly menu documented the daily diet to be of quality necessary to meet the needs of the residents. The facility has an approved Waiver to utilize Bella Vista Retirement (#197608297) as the food headquarter to store, prepare, serve, and transport meals to Arbor Vista was granted by CCLD. LPA/RA reviewed Witness #1 [local law enforcement police report (dated 09/13/21)] attempts made by W1 & W3 to encourage R1 to eat the food served at the facility; however, R1 refused food service. Resident #1 was also encouraged to go and see a doctor to be assessed; however, the resident refused medical services. W1 & W3 notified W4. Interviews conducted by facility staff corroborated that R1 had stopped eating for five (5) days and refused medical treatment from doctors. Facility Staff contacted (9-1-1) to respond to the facility as Resident #1 was later transported to the hospital on 09/13/21. A review of the "Pre-hospital Care Report" (dated 09/13/21) documented that the patient (R1) was advised multiple times by assisted-living staff to go with transport (9-1-1) to the hospital; but, patient (R1) repeatedly refused and stated that this was too much for the patient (R1) right now. Patient (R1) was advised of risks and consequences and advised to seek alternative medical care. Patient (R1) understood the consequences of refusal of medical services by hospital staff. Patient (R1) signed an AMA (against medical advice). Resident #1 did not return to the facility following hospital discharge.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Facility did not ensure that resident was adequately fed is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed a review of R1's "Emergency I.D. and Information" (dated 11/23/09) documented that Resident #1 is their own responsible person and present/legal guardian. A review of the "Unsual Incident/Injury Report" (dated 09/13/21) documented the incident and immediate action

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210916162357

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: 09/29/2022

NARRATIVE

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taken by facility staff (including persons notified) that included R1's family member (Witness #2) and CCLD. Interviews conducted by facility staff corroborated that R1 was their own responsible person; but, R1 did have family.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of REPORTING REQUIREMENTS: Facility staff did not notify resident’s representative of a change in the resident’s condition in a timely manner is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to the Administrator, Kim Commodore.

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC9099 (FAS) - (06/04)

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