197607820-10-24-2022-28-AS-TVAO-CKTQAW-20221103120033

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607820
Report Date: 10/24/2022
Date Signed: 10/24/2022 03:18:15 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, 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
07/15/2020 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20200715115541

FACILITY NAME:	REGENCY PARK ASTORIA		FACILITY NUMBER:	197607820
ADMINISTRATOR:	ANNABELLE ARGENAL		FACILITY TYPE:	740
ADDRESS:	925 EAST VILLA STREET		TELEPHONE:	(626) 796-4303
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	220	CENSUS: 84	DATE:	10/24/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Richard Kale - Executive VicePresident Anabelle Argenal - Assistant Administrator Brianna Goodlet - Assistant Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Severe neglect resulting in resident developing stage 4 pressure injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores and Licensing Program Manager (LPM) Tony Vasallo met with Richard Kale Executive VicePresident, Anabelle Argenal Assistant Administratro, and Brianna Goodlet Assistant Administrator during an office meeting to deliver findings for complaint regarding the above allegation(s).

On 7/16/20 due to COVID 19 restrictions LPA conducted a virtual 24 hour health and safety check of facility's common areas, kitchen, courtyards, and rooms #105,116,117,148B,238,244,246,249,254 with the assistance of Administrator. LPA requested a copy of staff/resident rosters, Physician's report, Needs and Care Plan, Emergency Identification Form, Hospice documents, Resident's Notes, and Unsual Incident Reports for residents #1,2,3,4,5,6,7,8,9,10 to be email to LPA by 7/17/20. On 7/16/20 the investigation was assigned to Investigator Laura Garcia of the Investigations Branch of the Department (IB) interviewed Administrator, resident #1's responsible parties, assistant administrator, staff members #1,#2,#4 (S#1,S#2,S#4).
(CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022

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-20200715115541

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: REGENCY PARK ASTORIA	FACILITY NUMBER: 197607820
	VISIT DATE: 10/24/2022

NARRATIVE

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On 8/10/20 LPA conducted a virtual visit and conducted interviews with Administrator, LVN/Nurse, Maricela Soria, and Med-Tech, Maria Arreola. LPA requested a copy of the following documents to be email to LPA: Med-Tech/Caregivers Notes, Incident Report for resident #1(R1), R1's doctor visit's discharge, 3 months Medication Sheets for R1, Doctor's communication notes, Caregivers schedule, Training within last year, Last Physician's Report for R1. On 3/23/21 LPA Flores delivered findings for allegation: Facility staff retained resident with prohibited health condition and that allegation was found to be substantiated. Facility was requested to provide in-service training on Skin Breakdown by 3/30/21. On 2/18/22 a referral was made to the department's program clinical consultant. Based on the record review the following was determined by program clinical consult there was sufficient evidence that the facility neglect to provide appropriate medical care and wound care.
Regarding Allegation: Severe neglect resulting in resident developing stage 4 pressure injury. It is alleged R1 developed a Stage 4 pressure injury on the right ankle and a Stage 2 pressure injury on the left heel. During the department's investigation: On 8/4/20 IB contacted R1's representatives, who denied being notified by the facility that R1 required wound care or a higher level of care. On 8/27/20 Administrator Lourdes Menchaca provided a copy of timeline of events and had limited knowledge of the resident's pressure injuries due to administrator being on a leave of absence from 5/13/20 to 7/29/20. Administrator stated that on 6/24/20 the facility's nurse noticed the wounds on R1. On 6/29/20 caregivers took the resident to Kaiser for a schedule appointment with family practice/nurse clinic and returned with no orders and two follow up appointments schedule for 7/1/20 and 7/7/20. On 6/30/20 facility's in-house nurse recommended to return with R1 to Kaiser Urgent Care to evaluate the wounds. Staff #2(S2) interviewed on 11/5/20 indicated to have been "only asked to escorted" R1 to doctor's appointment on 6/30/20, during this appointment R1 was prescribed ointment medication and returned to the facility. On 7/7/20 S2 escorted R1 to primary doctor's appointment and assisted the doctor to remove bandages on R1 wounds. During this appointment physician diagnosed R1 with a stage 4 pressure injury to the right ankle and an ulcer of the left lateral heel. On 7/7/20 R1 was admitted to Garden Crest Rehabilitation Center for care. Interview with staff #3(S3) on 11/11/20 indicated to have noticed a "tiny hole" on R1's ankle on 6/24/20 and recognize "that caregivers failed to notice the wounds". IB's document review revealed that Physician Report dated 9/3/19 showed no history of skin breakage and was non-ambulatory. No logs/notes were available to record R1's care. Training was provided in warning signs of skin break on 8/21/20.

Based on interviews and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM***

An exit interview was conducted with and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20200715115541

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: REGENCY PARK ASTORIA	FACILITY NUMBER: 197607820
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/25/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee provided staff training on Bed Sores, Signs of Skin Breakdown, Prevention, and treatment on 8/21/20. Deficiency cleared as of 8/21/20.
	8 9 10 11 12 13 14	Based on documents review, and interviews licensee did not ensure R1 was provided proper medical care upon wounds observation which poses an immediate health, safety, or personal rights risk to the person in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC9099 (FAS) - (06/04)

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