197606597-3-23-2022-31-AS-CHAS-CEHRUP-20220517132012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606597
Report Date: 03/23/2022
Date Signed: 03/23/2022 06:04:30 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/19/2021 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20210319153913

FACILITY NAME:	WESTPORT HOME		FACILITY NUMBER:	197606597
ADMINISTRATOR:	MORENA MARTINEZ		FACILITY TYPE:	740
ADDRESS:	10252 EAST AVENUE S		TELEPHONE:	(661) 944-5779
CITY:	LITTLEROCK	STATE: CA	ZIP CODE:	93543
CAPACITY:	20	CENSUS:	DATE:	03/23/2022
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:			TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident death due to staff neglect.
Facility staff failed to seek medical attention in a timely manner

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPA Spaeth conducted an unannounced complaint visit and met with T. Cambiado, Manager of the Facility. LPA Spaeth discussed the purpose of the visit was to report the findings of the investigation regarding the complaint dated March 19, 2021. Within the complaint, two allegations stated the resident’s death was due to staff neglect and due to the resident not receiving medical care in a timely manner. The complainant also stated a facility caregiver had reported to complainant that resident’s health had declined. Resident #1 (R1) was taken to the hospital and received treatment on January 10, 2021 but resident died on January 20, 2021. The complainant was concerned because R1 did not receive the treatment in a timely manner which resulted in the resident’s death.
The complaint report was forwarded to the Investigative Bureau via fax. A full investigation was conducted by Investigator Edward Hector. The IB Investigator obtained and reviewed the medical records from Palmdale Regional Medical Center on May 10, 2021. According to the medical records, R1 was admitted via ambulance to the hospital on January 9, 2021 and the admitting diagnosis was “pneumonia toxic encephalopahthy.” The medical records also stated the resident was hospitalized and tested positive for a

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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 31-AS-20210319153913

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WESTPORT HOME	FACILITY NUMBER: 197606597
	VISIT DATE: 03/23/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

contagious virus, pneumonia, and other ailments. The resident expired on January 20, 2021. The official cause of death was respiratory failure with hypoxia due to pneumonia and septic shock.

The IB Investigator interviewed previous staff member (S1) on July 17, 2021. S1 stated during the month of January 2021, the resident stopped eating, was not “cohesive” and was not giving the resident’s “normal” replies. S1 stated the resident stopped drinking liquids when resident’s condition deteriorated and observed the resident’s body began to shake. S1 recognized the change in the resident’s condition either January 1, 2021 or January 2, 2021. S1 claimed caregivers called resident’s physician two days after observing this initial change of condition but does not remember what plan of care the physician stated was needed.

The IB Investigator also interviewed former staff member (S2) on June 17, 2021. S2 stated they noticed R1’s change of condition two days prior to R1’s admission to the hospital. S2 stated resident was lethargic. S2 contacted resident’s doctor but stated they could only leave messages. S2 stated the doctor did not return the calls. S2 stated R1’s condition got worse on the day the resident was sent to the hospital. S2 stated R1 was “very pale, very shaky and just did not look well.” As a result, S2 could no longer wait for a return call from the doctor and stated they needed to send the resident to the hospital.

The IB Investigator interviewed Staff #3 (S3) on June 17, 2021. S3 confirmed they had been working at the facility since February 2021 and confirmed that they oversee food and supply inventory and oversees ordering of medications for the residents. S3 also confirms overseeing the day-to-day operations of the facility. S3 confirmed they had no information regarding the care of the former deceased resident and stated they began working after former administrator, Staff #4 (S4) stopped working at the facility. S3 also confirmed there was no documentation within the facility stating the reason why R1 was transported to the hospital.

Based on IB Investigator Hector’s investigation and findings, the allegations of “Resident death due to staff neglect” and “Facility staff failed to seek medical attention in a timely manner” are deemed substantiated. Based on the Investigator’s review of the medical records and staff interviews and pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

A $500 immediate civil penalty is assessed today for a violation resulting in injury/death to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Additional investigation may be needed at this time. Exit interview conducted. Appeal rights given. A copy of the report was issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20210319153913

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WESTPORT HOME	FACILITY NUMBER: 197606597
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/01/2022 Section Cited CCR 87466	1 2 3 4 5 6 7	The licensee shall ensure that residents are regularly observed for changes in physical, ... functioning & that appropriate assistance is provided when such observation reveals unmet needs. When changes such as ... physical health condition are observed, the licensee shall ensure such chanes are...brought to the attention of resident's physician...	1 2 3 4 5 6 7	Licensee will.provide care and supervisition training through a vendored location and needs to be completed by April 1, 2022. Also, Licensee will provide a certificate of completion by all staff and a sign in sheet signed by staff indicating staff completed the training.
	8 9 10 11 12 13 14	This requirement was not met as evidencd by: Based on the information obtained during the course of the investigation the licensee/Administrator and staff did not comply with the section cited by not providing proper care and supervision to R1 which resulted in R1’s death which posed an immediate health and safety risk to R1.	8 9 10 11 12 13 14	Because this violation resulted in the death of the resident, an immediate civil penalty in the amount of $500 is issued.
Type A 03/23/2022 Section Cited CCR 87464	1 2 3 4 5 6 7	(f) Basic Services shall at a minimum include (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). This requirement was not met as evidenced by: Based on the	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	information obtained during the course of the investigation, the licensee/Administrator and staff did not comply with the section cited by not providing proper care and supervision to R1 which resulted in R1's death which posed an immediate health and safety risk to R1.	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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3