197606893-5-7-2021-28-AS-MVAO-C35R3F-20210518123948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606893
Report Date: 05/07/2021
Date Signed: 05/07/2021 10:53:00 AM

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
09/30/2019 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20190930135103

FACILITY NAME:	TIFFANY'S BOARD AND CARE IV		FACILITY NUMBER:	197606893
ADMINISTRATOR:	COSTANCE EDWARDS		FACILITY TYPE:	740
ADDRESS:	16955 JANINE DRIVE		TELEPHONE:	(562) 690-9274
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	6	CENSUS: 2	DATE:	05/07/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Tiffany Sasada, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

The resident was prescribed inappropriate medications.
Resident was diagnosed with dehydration and hospitalized.
Staff failed to seek timely medical treatment.
Staff failed to report changes of medications to responsible party.
Staff failed to provide documentation of the resident's care to the hospital personnel when requested.
Food service inadequate.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) N.Galarza initiated a complaint investigation for the purpose of delivering findings on the above allegations. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Tiffany Sasada.

The investigation consisted of the following: On 10/4/2019, at 2:03 pm LPA toured the physical plant and inspected the kitchen and food supply. Sufficient food supply was observed. No signs of neglect were observed. Staff (S1- S3) were interviewed. Due to resident's cognitive impairments no residents were interviewed on that date. Resident (R1's) file was reviewed. The following documents were obtained: [ Identification and Emergency Information/ DL, Admission Agreement, Resident Appraisal, Centrally Stored Medication and Destruction Record [Months September 2018- October 2018], LIC 500 Personnel Report, Staff Schedule, Resident Roster, Medication Rules, House Rules]. NOTE: NO Physician's Report was provided. Investigations Branch (IB) Investigator Douglas Real investigated allegation #2, and obtained medical records. LPA conducted an additional interview with CareMore Touch Nurse Practioner. ***See LIC 9099C for continuation of report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

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-20190930135103

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: TIFFANY'S BOARD AND CARE IV	FACILITY NUMBER: 197606893
	VISIT DATE: 05/07/2021

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

Allegation 1: The resident was prescribed inappropriate medications. Based on interviews conducted and document review, resident (R1) was admitted to the facility on 9/25/2018. Resident's medications were prescribed by Kaiser Permanente physician. Resident received home health services via CareMore Touch. On 10/1/2018 CareMore Health stopped Trazadone medication and started Temazepan, Depakote, and Ativan. Medications were changed due to reports by staff and resident (R1's) family that resident had increased agitation and aggression. On 10/3/2018 medication "Trazadone" medication was discharged per CareMore Health notes. Medication discharge note was obtained. Medication side effects were noted by facility staff on 10/5/2018 and Administrator was told by CareMore Nurse Practioner to decrease Depakote, not use Ativan, and monitor the resident until 10/8/2018. Facility followed MD medication orders as directed.

Allegation 2: Resident was diagnosed with dehydration and hospitalized. Department of Social Services- Investigation Branch Investigator Douglas Real investigated this allegation. Facility documents and medical records were reviewed. Investigator conducted interviews with staff, CareMore home health Nurse Practitioner, residents, and resident's family members. All staff stated attempts to hydrate and feed R1 were made, but R1 often refused. Administrator contacted CareMore Nurse Practioner and reported change in condition after medication changes. On 10/8/2018, Care More NP arranged for resident (R1) to be transported to a Skilled Nursing Facility (SNF). SNF then transported R1 to PIH Health Hospital Whittier. Resident was admitted with dehydration. Medical records obtained diagnosed resident (R1) with Aspiration Pneumonia. Resident's worsening physical condition at the facility, as well as not eating or drinking sufficiently could have reasonably been caused by R1's advance in Alzheimer's illness. Per CareMore Nurse Practioner no neglect or abuse concerns were noted. The information and evidence obtained did not sufficiently support the allegation.

Allegation 3: Staff failed to seek timely medical treatment. The findings indicate that resident moved in to the facility on 9/25/2018. On 10/5/2018 Administrator notified Nurse Practioner (NP) of significant side effects to medication changes. Per NP, staff was instructed to continue administering medication until 10/8/2018. Resident (R1) was receiving Care More Touch home health services by Nurse Practioners. Per Administrator interview, on 10/5/2018 CareMore Nurse Practioner did not think the resident needed immediate medical treatment when R1 began displaying medication side effects, since it is common when there are medication changes. One of the side effects was excessive sleep. Nurse notes did not indicate immediate care was needed on that date. On 10/8/2018, CareMore Nurse Practioner re-evaluated resident (R1), and concluded resident required higher level of care due to illness decline. Nurse Practioner made arrangements to transport R1 to a Skilled Nursing Facility (SNF), because at 2:30 pm resident's " vitals were stable and deemed safe to go to nursing home for IV hydration." Once at Skilled Nursing Facility (SNF) staff stated R1's oxygen saturation dropped to 81%. Resident was transported via 911 to PIH Whittier Hospital where resident was admitted with dehydration and later diagnosed with bilateral pneumonia.
SEE NEXT PAGE

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20190930135103

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: TIFFANY'S BOARD AND CARE IV	FACILITY NUMBER: 197606893
	VISIT DATE: 05/07/2021

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

Allegation 4: Staff failed to report changes of medications to responsible party. Based on interviews conducted with facility staff and CareMore Nurse Practioner the findings reveal that resident (R1's) responsible party was notified of medication changes ordered by R1's doctor. New medications were prescribed in order to treat escalating agitation and aggressive behaviors. Nurse Practioner stated that a non CareMore doctor changed R1's Trazadone medication to Divalproex. It is alleged that responsible party did not authorize medication changes. Per, CareMore home health interview resident's responsible party does not have to authorize medication changes. Administrator stated that multiple texts were exchanged with responsible party regarding medication changes.

Allegation 5: Staff failed to provide documentation of the resident's care to the hospital personnel when requested. Administrator stated that on 10/8/2018 CareMore Nurse Practioner arranged transportation to Skilled Nursing Facility (SNF) for the resident. The list of medications were sent with the resident when the transport company picked up the resident. In addition, CareMore case manager sent medication list to SNF as well. Resident (R1) was sent to PIH Whittier Hospital on the same date. Facility Administrator was contacted when resident was hospitalized. Administrator stated that family and hospital was informed that medication list/information was sent with the resident when it was transported to the SNF. It is unknown if SNF facility forwarded the documents to the hospital. There is insufficient evidence to prove that hospital requested the documents from facility staff.

Allegation 6: Food service inadequate. Based on staff interviews and a physical plant tour conducted on 10/4/2019, LPA inspected the kitchen, food supply, and residents in care. Sufficient food supply was observed at the time of the visit, and no health and safety issues were observed. Staff interviews revealed resident (R1) was being given fluids, puree diet, Ensure drinks as tolerated, but only ate approximately 50% of the food item given. Staff reported that resident (R1) refused to open its mouth, and ate very little. Staff stated residents are not forced to eat, but they are constantly offered fluids and food whether they are ambulatory or bedridden.

Based upon records review, interviews conducted, and observations made the findings indicate that, although the allegation(s) 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.

A telephonic exit interview was conducted with Administrator Tiffany Sasada. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3