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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608129
Report Date: 04/22/2022
Date Signed: 04/22/2022 11:26:00 AM

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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/20/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20201120161534
FACILITY NAME:RESIDENCES AT ROYAL BELLINGHAM, THEFACILITY NUMBER:
197608129
ADMINISTRATOR:LORI MCKAYFACILITY TYPE:
740
ADDRESS:12229 CHANDLER BOULEVARDTELEPHONE:
(818) 980-2997
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:96CENSUS: 76DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lori McKay & Lito VitugTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident sustained pressure injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith initiated a subsequent complaint investigation to issue findings for the above allegations. The LPA met with Lito Vitug & Lori McKay and explained the reason for the visit.

On 11/20/2020, the Department received a complaint which alleged that due to lack of care and supervision, Resident #1 (R1) developed multiple pressure injuries. The initial visit was conducted virtually on 11/23/2020 from 12:45 p.m. to 1:30 p.m. by LPA Zabel Chochian, in which LPA Chochian interviewed staff and requested documents. LPA Ashley Smith conducted a subsequent visit on 03/15/2022, and the LPA conducted a tour at 9:20 a.m., conducted a file review at 10:20 a.m., and obtained documents. The LPA conducted the following interviews: staff interviews at 9:27 a.m., 10:35 a.m., 11:20 a.m., and 1:06 p.m.; resident interviews at 9:23 a.m., 10:30 a.m., and seven resident interviews from 1:20 p.m. - 2:00 p.m.; and, an interview with a collateral agency representative at 1:01 p.m. In addition, the LPA interviewed family members of R1 on 3/15/2022 at 11:51 a.m. and 12:06 p.m. Lastly, home health and hospital records were requested and reviewed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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 4
Control Number 29-AS-20201120161534
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: RESIDENCES AT ROYAL BELLINGHAM, THE
FACILITY NUMBER: 197608129
VISIT DATE: 04/22/2022
NARRATIVE
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Regarding the allegation, it was alleged that R1 developed multiple pressure injuries while in care. R1 was admitted to this facility on 11/17/2017 without the presence of wounds or injuries. A Physician’s Report dated 2/15/2019 noted that R1 had a diagnosis of osteoporosis and mild cognitive impairment, yet there was no indication of pressure injuries or skin integrity issues. Interviews revealed that R1 declined while residing at the facility and ultimately became bedbound. It was noted that although staff would reposition R1 regularly, staff interviews and interviews with R1’s family noted that R1 ‘favored’ their left side.

Records review indicated that on 6/5/2020, R1 began receiving home health services for an unstageable pressure injury on the left hip. A review of home health records revealed that a home health nurse provided daily wound care for the unstageable pressure injury from 06/05/2020 – 8/28/2020. The records demonstrated that due to daily wound treatment, the pressure injury gradually shrank in size. On 8/28/2020, R1 was discharged from home health as the pressure injury had closed. Thereafter, there were no records to indicate that R1 received additional home health services.

The investigation revealed that a nurse from the Assisted Living Waiver Program (ALWP) would visit the facility weekly to take vitals for residents enrolled in the ALW program. As such, the LPA reviewed the charting notes for R1 from June 2020 – November 2020. Interviews and documentation review revealed that the ALWP nurse indicated that R1 was receiving home health services for a ‘left hip wound’ from 6/5/2020- 8/26/2020. Thereafter, there was no mention of a pressure injury or other wounds in subsequent weekly visits. However, on 10/28/2020, the nurse documented that the staff should reposition R1 every two hours, reason unknown. On 11/11/2020, it was documented that R1 had a stage one pressure injury on the left hip. There was no evidence to indicate whether the ALW nurse or facility staff informed R1’s physician about the presence of the pressure injury. On 11/17/2020, the nurse noted that R1 was hospitalized. However, interviews and record review provided insufficient evidence as to whether the ALWP nurse provided any wound care during their visits on 10/28/2020 or 11/11/2020.

Hospital records indicated that R1 was sent to the hospital on 11/17/2020 due to a change of condition. R1 was admitted on 11/17/2020 at 1:20 p.m. with a diagnosis of failure to thrive, hypernatremia, acute kidney injury, and pancreatitis. Upon admission to the hospital, R1 was found with deep tissue pressure injuries on the left shoulder, left buttock and left foot. Per the National Pressure Injury Advisory Panel, deep tissue pressure injuries “… result from intense and/or prolonged pressure and shear forces at the bone-muscle interface.” R1 did not return to the facility.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20201120161534
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: RESIDENCES AT ROYAL BELLINGHAM, THE
FACILITY NUMBER: 197608129
VISIT DATE: 04/22/2022
NARRATIVE
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Based on the investigation, there is sufficient evidence to support the claim that R1 developed pressure injuries while in care. Whereas R1 received appropriate wound care for the unstageable pressure injury on 06/05/2020 by home health, an unstageable pressure injury is considered a Prohibited Health Condition. The LPA could not identify records to indicate that an exception request was submitted in order for R1 to remain at the facility. In addition, interviews and records review confirmed that R1 did not receive hospice services while residing at this facility. R1’s unstageable pressure injury healed on 8/28/2020, yet R1 was admitted to the hospital on 11/17/2020 with multiple deep tissue pressure injuries. Although records indicated that a stage one pressure injury was known on R1’s left hip, staff appeared unaware about the deep tissue pressure injuries on R1’s left shoulder and left foot. In fact, interviews conducted during the 11/23/2020 visit revealed that staff believed they did not have a resident in the community with a pressure injury at the time of the visit.

The allegation is ‘resident sustained pressure injuries while in care’ is Substantiated at this time.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. Exit interview conducted. A copy of the report was issue, along with appeal rights.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20201120161534
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RESIDENCES AT ROYAL BELLINGHAM, THE
FACILITY NUMBER: 197608129
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2022
Section Cited
CCR
87615(a)(1)
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87615(a)(1) Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained...: (1) Stage 3 and 4 pressure injuries.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Schedule a training regarding Pressure Injuries and Healing Wounds. Verification of scheduled training with the trainer’s credentials will need to be submitted by 4/25/2022 and completion of training must be submitted no later than 5/13/2022.
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Based on the investigation, the licensee did not comply with the section cited above, as R1 was retained with an unstageable pressure injury and was hospitalized with multiple deep tissue pressure injuries, which poses an immediate health and safety risk to residents in care.
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An immediate civil penalty of $500 is also assessed.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4