197607820-3-23-2021-28-AS-TVAO-CKTQAX-20221103120034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607820
Report Date: 03/23/2021
Date Signed: 03/23/2021 04:57:43 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: 55	DATE:	03/23/2021
		UNANNOUNCED	TIME BEGAN:	03:13 PM
MET WITH:	Brianna Goodlet - Assistant Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility staff retained resident with prohibited health condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted a complaint investigation visit for the above allegation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Brianna Goodlet, the facility assistant administrator.

The investigation consisted of the following: On 7/16/20 LPA conducted a virtual 24 hour health and safety check of facility of 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. On 8/10/21 LPA conducted a virtual visit and conducted interviews with Administrator Lourdes Menchaca, LVN/Nurse, Maricela Soria, and Med-Tech, Maria Arreola. LPA requested a copy of the following documents: 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 withing last year, Last Physician's Report for R1.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021

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-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: 03/23/2021

NARRATIVE

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The investigation revealed the following: Regarding allegation; Facility staff retained resident with prohibited health condition. It is allege resident develop stage 4 pressure injures. This is the chronological line of events based on documents reviewed. On 6/29/20 Resident #1(R1) visited Kaiser Permanente's family practice office for an appointment. On 6/30/20 R1 visited Kaiser Permanente's urgent care upon discharge, discharge documents notes stated R1 had an ulcer in left foot and an ulcer in right foot, ointment was prescribed and resident returned to the facility. On 7/7/20 R1 visited Kaiser Permanente family practice, discharge documents state R1 had a pressure ulcer of right ankle stage 4. Upon discharge R1 was admitted to a higher level of care facility on 7/7/20. R1 was not receiving hospice and/or home health care. Based on interviews with facility's staff, On 6/24/20 caregiver notified administration of redness observed in R1 right ankle. On 7/1/20 facility's staff contacted R1's physician to request Home Health care evaluation. Facility retained R1 at the facility with a diagnose of ulcers in right and left foot.

Based on interviews conducted and documents review, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 is being cited on LIC 9099D.

Exit interview was conducted with Brianna Goodlet, Assistant Administrator. A copy of this report was email for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/24/2021 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615 Prohibited Health Conditions; (a) Persons who require health services for or have a health condition including, but not limited to,... shall not be admitted or retained in a residential care facility for the elderly: (1)Stage 3 and 4 pressure injuries. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Facility will provide in-service training for staff within 7 days and will submit a copy of in-service training along with signing sheet. In addition facility will submit LIC 9098 Proof of Correction form by 3/24/21.
	8 9 10 11 12 13 14	Based on interviews, and documents review facility retained R1 from 6/30/20 to 7/7/20 with a pressure injury resulting in stage 4 pressure injury which poses an immediate Health, Safety, Personal Rights risk to 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: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021

LIC9099 (FAS) - (06/04)

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