197607558-4-28-2022-28-AS-TVAO-CZLTXN-20240118140718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607558
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:22:10 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
04/25/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220425115420

FACILITY NAME:	CARTER PLACE, THE		FACILITY NUMBER:	197607558
ADMINISTRATOR:	ARGIRI BRATAKOS		FACILITY TYPE:	740
ADDRESS:	400 W. CARTER AVE.		TELEPHONE:	(626) 374-4920
CITY:	SIERRA MADRE	STATE: CA	ZIP CODE:	91024
CAPACITY:	6	CENSUS: 3	DATE:	04/28/2022
		UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Crystal Galvan - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff do not adhere to COVID-19 protocol
Staff did not notify appropriate parties regarding resident's change in condition
Staff do not follow resident's physician's order
Staff do not distribute resident's self administered medications as prescribed
Staff do not communicate with appropriate parties
Facility doesn't provide accommodation for resident's visiting
Facility did not record resident's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Crystal Galvan administrator and explained the reason for the visit.

The investigation consisted of the following: LPA conducted interview with administrator, requested copies of staff and resident roster. Interviewed resident #1(R1),#2(R2),#3(R3), and staff #1(S1),#2(S2). LPA reviewed files for R1,R2,R3, resident #4(R4) and requested copies of admission agreement, preplacement appraisal, appraisal needs and service plan, physician's report, medication sheet, record of resident's safeguarded cash resources, resident personal property and valuables, identification and emergency information, screening and visitor's log for March and April 2022 for R1,R2,R3,R4 and power of attorney, physician's progress notes, home health care documents for R4, and staff training.

(CONTINUED LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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 5

Control Number 28-AS-20220425115420

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: CARTER PLACE, THE	FACILITY NUMBER: 197607558
	VISIT DATE: 04/28/2022

NARRATIVE

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The investigation revealed the following: Regarding allegation: Staff do not adhere to COVID 19 protocol. It is alleged, staff do not wear masks and staff do not screen visitors for COVID-19 symptoms prior to entering the facility. At the time of the visit LPA observed through the kitchen's door glass S1, and S2 wearing a face mask before walking to the point of entrance, where a sign in log was available to record temperature taken prior entering the facility and a questionnaire for symptoms, staff continued to wear face mask during the visit. During interviews with residents 2 out 3 residents stated staff wear a face mask at all times at the facility and 1 out 3 residents interview was unable to answer due to cognitive or verbal skills. Administrator stated facility continues to follow COVID 19 protocols and interviews with staff revealed 2 out of 2 staff stated to wear a face mask through out the day at the facility and continue to screen visitors. Documents reviewed revealed logs are maintain for screening of visitors.

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 is UNSUBSTANTIATED.

Regarding allegation(s): Staff did not notify appropriate parties regarding resident's change in condition and Staff do not communicate with appropriate parties. It is alleged staff did not notify resident's family regarding wound care for R4 and did not give a reason to family representatives regarding R4's room change. Interview with administrator revealed R4 has a conservator and communication is conducted with conservator as request. Room change for R4 has not happen, R4 continues to be in the same since time of admission. LPA Flores interviewed court appointed conservator who stated that facility has communicated with conservator regarding changes in condition via email. Administrator forward emails and text messages of communication between administrator and conservator in which administrator discusses wound care and protocol to follow by facility, physician, to move forward with care.

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 is UNSUBSTANTIATED.

Regarding allegation: Staff do not follow resident's physician's order: It is alleged there are physician's order regarding elevating the resident's legs at all times. However, staff do not elevate the resident's legs. 3 out 3 residents were unable to answer questions regarding care due to cognitive or verbal skills. Administrator stated there is no written order by a physician for rotating or elevating legs but have been instructed by Home Health Nurses to rotate hips and elevate legs every two to three hours. (CONTINUED LIC 9099C)

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20220425115420

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: CARTER PLACE, THE	FACILITY NUMBER: 197607558
	VISIT DATE: 04/28/2022

NARRATIVE

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2 out of 2 staff stated to assist residents with need to rotate or elevate every 2 hours although residents are not in the same position all day as they get out of bed, or are moved to chair throughout the day. Documents review revealed there are no doctor's notes or orders regarding rotating or elevating legs for residents on file.

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 is UNSUBSTANTIATED.

Regarding allegation: Staff do not distribute resident's self administered medications as prescribed. It is alleged, staff are mixing resident's medications into pudding, breakfast, lunch, dinner meals, and liquids. Interviews with 2 out of 3 residents revealed medication is placed next to them for them to take the medication. 1 out of 3 residents was unable to answer due to cognitive or verbal skills. Administrator stated medication is provided to the residents by placing it in hand, unless placed in spoon per request and staff watch for resident to take the medication, medication is not placed in food as there is no doctor's request for any of the residents. 1 out of 2 staff stated to assist with medication by providing the medication in cup or spoon, and 1 out of 2 staff stated not to assist with medication but there is a resident that likes her medication with chocolate pudding. Documents reviewed revealed there are no doctor's orders for medications to be hidden from residents to take. Medication sheets revealed medications are listed for each resident with medication name, and instructions.

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 is UNSUBSTANTIATED.

Regarding allegation: Facility doesn't provide accommodation for resident's visiting. It is alleged facility has changed the time that residents can have visitors, resident's can only visits until 6PM. Interviews with residents revealed 1 out of 3 residents interview stated family visits and visit without difficulty. 1 out of 3 residents stated not to receive visits but family calls. 1 out of 3 residents was unable to answer due to cognitive or verbal skills. Administrator stated that visitation policies/hours have been change to 9:00am to 6:00pm during the pandemic and visitors have been asked to notify staff prior visit to minimize the number of people due to nurse or physician's visits conducted throughout the day. However administrator accommodates family when necessary after visiting hours. Regarding R4 facility has a visiting schedule for family representatives per conservator. 2 out of 2 staff stated residents receive visitors between 9:00am to 6:00pm. Documents reviewed revealed visitors sign in and there are visitors that have sign in after 6:00pm.
(CONTINUED LIC 9099C)

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20220425115420

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: CARTER PLACE, THE	FACILITY NUMBER: 197607558
	VISIT DATE: 04/28/2022

NARRATIVE

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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 is UNSUBSTANTIATED.

Regarding allegation: Facility did not record resident's personal belongings. It is alleged staff did not take inventory and record the resident's personal belongings upon admission. 3 out of 3 residents interview were not able to answer questions regarding personal belongings due to cognitive or verbal skills. Administrator stated that upon admission a record of resident's property and valuables form for each resident is filled. 2 out of 2 staff interview stated that the facility keeps a list of the items resident comes with or continues to bring to the facility. During file review LPA found a copy of the resident's property and valuables form in each file 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 is UNSUBSTANTIATED.

Exit interview was conducted with Crystal Galvan administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC9099 (FAS) - (06/04)

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