197606145-12-1-2021-28-AS-FFIS-C9Q6HD-20211214194921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606145
Report Date: 12/01/2021
Date Signed: 12/01/2021 12:41:11 PM

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
05/15/2019 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20190515163549

FACILITY NAME:	ARCADIA GARDENS RETIREMENT HOTEL		FACILITY NUMBER:	197606145
ADMINISTRATOR:	PAT REDNER		FACILITY TYPE:	740
ADDRESS:	720 W. CAMINO REAL		TELEPHONE:	(626) 574-8571
CITY:	ARCADIA	STATE: CA	ZIP CODE:	91007
CAPACITY:	200	CENSUS:	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	11:31 AM
MET WITH:	Pamela Parsons, Administrator		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries due to neglect.
Staff left resident in soiled diapers for an extended period of time.

INVESTIGATION FINDINGS:

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***This licensing report supersedes the complaint investigation report dated 07/01/2020. The findings have been changed to Unsubstantiated***

The initial investigation was conducted on 05/17/19, during visit, LPA Day, reviewed resident records, interviewed residents, Owner, Administrator and LPA Day toured the facility. Subsequent visits were conducted on 01/03/20 and 06/12/20. During the subsequent visits, LPA Day interviewed Administrator Pat Redner, attempted to interview Resident #1 (R#1) and Resident #1 private caregiver, however, R#1 and R#1 private caregiver were not available. LPA Day reviewed R#1 facility file and received copies of R#1's Admission agreement, Face sheet and ID information, last physical, pre-placement appraisal and medication log and interviewed administrator Pat Redner and two (2) facility staff.

(- Continued in LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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-20190515163549

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: ARCADIA GARDENS RETIREMENT HOTEL	FACILITY NUMBER: 197606145
	VISIT DATE: 12/01/2021

NARRATIVE

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On 05/19/21, LPA Tao obtained copies of Staff and Residents rosters, toured the physical plant and did not observe that facility staff were not assisting with residents with incontinent care and LPA Tao did not observe any unusual odors in the facility.

During the investigation, LPA Tao interviewed with Resident#2-#12 and Staff#2-#5 and Staff#11; reviewed R#1 medical records and R#1 facility file. In addition, on 08/22/19, LPA Razo conducted interviews with staff #6-#10.

In regard of allegation: Resident sustained multiple pressure injuries due to neglect.

The investigation revealed the following. The allegation was alleged that R#1 received extensive skin damage due to moisture and had multiple pressure injuries. Former Administrator Pat Redner denied the allegations. Per resident interviews, ten (10) out of twelve (12) residents stated they were not aware of a resident who sustained pressure injuries due to neglect. One (1) of twelve (12) residents was unable to answer LPA's questions. LPA Tao was unsuccessful in attempts to interview R#1, who has been relocated and lost contact. Interviews with eleven (11) out of eleven (11) staff indicated that staff denied knowledge that a resident sustained multiple pressure injuries due to neglect. Interviews with staff revealed that staff provided care to R#1 by repositioning/turning R#1 every two hours and elevated R#1's feet while R#1 was in chair and/or bed. During a site visit on 05/19/21, LPA Tao observed staff would assist residents who required assistance with repositioning as needed.

The investigation revealed the following, R#1 was admitted to the facility on 01/21/19, upon admission to the facility, R#1 had redness to inner buttock, left and right legs.

(-Continued in LIC 9099 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20190515163549

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: ARCADIA GARDENS RETIREMENT HOTEL	FACILITY NUMBER: 197606145
	VISIT DATE: 12/01/2021

NARRATIVE

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From date of admission through 05/04/19, staff assisted R#1 with changes of R#1 adult briefs due to incontinence care and repositioned R#1 as needed. There was no evidence to support that staff left R#1 skin moist or wet. Review of R#1's records; including medical records revealed that R#1 was admitted to Arcadia Methodist Hospital on 05/05/19 for general weakness and not feeling well. Upon admission to the hospital, it was noted by medical staff that R#1 had redness on resident's inner buttocks, left and right legs. On 05/06/19, the hospital’s physician ordered a test to determine and assess if R#1’s wounds were due to artery blockage since the wounds appeared to be arterial in nature. The results of the test were received on 05/06/19, which indicated R#1 wounds were caused by poor blood circulation or artery blockage and not by moisture on the skin. The investigation did not reveal that staff neglected R#1, resulting in R#1 sustaining wounds.

In regard of allegation: Staff left resident in soiled diapers for an extended period.
The investigation revealed the following. Per the complaint, it was alleged that Resident #1 was left in soiled diapers for an extended period. Administrator denied the allegation. Per resident interviews, seven (7) out of twelve (12) residents who use adult briefs stated staff did not leave them in soiled diaper for an extended period

Three (3) out of twelve (12) residents who did not use adult briefs stated they were not aware of residents who used adult briefs complaining of staff leaving residents in soiled diaper for an extended period. One (1) of twelve (12) residents was unable to answer LPAs questions. LPA Tao was unsuccessful in attempts to interview R#1, since resident has been relocated and lost contact resident.

(-Continued in LIC 9099 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20190515163549

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: ARCADIA GARDENS RETIREMENT HOTEL	FACILITY NUMBER: 197606145
	VISIT DATE: 12/01/2021

NARRATIVE

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Interviews with eleven (11) of eleven (11) staff revealed that staff would change residents' diapers in a timely manner. Per staff interviews, staff denied residents were being left in soiled diapers for an extended period and changed resident’s adult briefs every two hours or as needed.
Review of resident record regarding resident who were incontinent and needed assistance with changing of adult briefs, revealed that staff changes resident’s adult briefs every two hours. Per LPA Razo's and LPA Tao’s observations during site visits conducted on 10/19/19 and 05/19/21, LPAs did not observe any foul odors or smell of urine at the facility. The investigation did not reveal any evidence to support that staff left residents in soiled diapers for an extended period. Therefore, there was insufficient evidence to corroborate with the allegation.

Based on the information obtained during the investigation, interviews with staff, residents, review of resident file/medical records and LPAs' observation, the investigation did not reveal any evidence to support the following allegations: Resident sustained multiple pressure injuries due to neglect and Staff left resident in soiled diapers for an extended period. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore, the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Administrator, Pamela Parsons and Licensee, Julie Chirikian. Findings were discussed. A copy this report was provided to Administrator at time of visit.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

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