197608268-8-24-2023-28-AS-TVAO-CV6T8F-20230829143017

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608268
Report Date: 08/24/2023
Date Signed: 08/24/2023 01:45:57 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
12/09/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20221209132559

FACILITY NAME:	HERITAGE SENIOR HOME CARE		FACILITY NUMBER:	197608268
ADMINISTRATOR:	NINO NAVARRO		FACILITY TYPE:	740
ADDRESS:	820 GLENLEA STREET		TELEPHONE:	(626) 272-1540
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	6	CENSUS: 5	DATE:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Nino Navarro - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not meet resident's care needs resulting in resident hospitalized for pneumonia, bacteria in blood and septic shock.
Resident sustained pressure injuries while in care.
Staff did not seek medical attention for resident in a timely manner.
Staff placed resident on hospice care without resident's POA's approval.
Staff did not ensure resident was fed.
Staff did not ensure resident was administered medications.
Staff did not ensure resident is involved with resident activities/Staff isolated resident in care.
Staff did not allow resident visitors.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Ronell Lopez caregiver. Administrator Michelle Navarro arrived 10 minutes later, and LPA explained the reason for the visit.

The investigation consisted of the following: On 12/12/22 LPA Flores conducted a 24-hour Health and Safety Check visit and requested copies of R1's file which include: Physician's Report, Medication Sheets, Identification and Emergency sheet form, Power of Attorney, Hospice evaluation letter and others. On 12/12/22 investigator Laura Garcia from the Investigation Bureau Department (IB) investigated the first allegation. On 8/24/23 LPA Flores conducted interviews with residents #1-#3(R1-R3), staff #1-3 (S1-S3), responsible parties for residents #4 and #5(R4-R5), requested visitor's logs for September to November 2022, and delivered findings for the allegations.

(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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-20221209132559

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE SENIOR HOME CARE	FACILITY NUMBER: 197608268
	VISIT DATE: 08/24/2023

NARRATIVE

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The investigation revealed the following: Regarding allegation: Staff did not meet resident's care needs resulting in resident hospitalized for pneumonia, bacteria in blood and septic shock. It is alleged R1 was diagnosed with double pneumonia, bacteria in the blood, and in septic shock. R1 was admitted to the facility on 8/5/20 upon admission R1 did not have hospice services. Caremore Health provided services to R1 from 6/15/22 to 10/17/22. On 9/12/22 Caremore Health ordered a chest x-ray for R1 due to cough. On 9/15/22 a plan was noted for treatment provided for R1’s pneumonia. On 10/17/22 Caremore Health nurse ordered a chest x-ray and urinalysis exams, and physician provided a referral for hospice evaluation. On 10/18/22 R1 initiated hospice services with Medplus Hospice Services. The reason for admission to hospice was due to overall decline, need for maximum assistance, and increased confusion and aphasia. On 11/8/22 R1 was admitted to the hospital per R1’s representative request. Upon admission to the hospital R1 was diagnosed with failure to thrive, septic shock, aspiration pneumonia, bacteremia, and other diagnosis. Although, R1 was diagnosed with the previously listed diagnoses, there is no evidence to support that the facility staff was neglectful in care. R1 was receiving home health care services and was admitted to hospice care. The facility and hospice nurse followed R1’s representative wishes when the decision to hospitalize R1 was made on 11/8/22.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Resident sustained pressure injuries while in care. It is alleged R1 developed two bed sores on R1’s coccyx and family member were never told about them. Caremore Health provided services to R1 from 6/15/22 to 10/17/22. Prior to being admitted to the facility on 8/5/20 R1 was at a skill nursing facility. Per skill nursing notes R1 had disorder of the skin and subcutaneous tissue. On 7/15/22 Caremore Health noted R1 had a small skin tear on the left buttock and provided care. On 7/28/22 a follow up visit was conducted for the wound which appeared to be healed. On 9/2/22 R1 was evaluated, and an assessment and plan were noted for a stage 2 pressure injury on left buttocks and sacrum by Caremore Health. On 9/6/22, 9/9/22, 9/15/22, and 10/6/22 R1 was provided wound care by Caremore Health. On 9/16/22 a referral for wound supplies was made by Caremore Health. On 11/8/22 hospital noted skin was dry. Interviews conducted with responsible party, and staff revealed R1 was visited once a week by a nurse from Caremore Health. Although R1 did developed wounds while in care. R1 was receiving care by a home health agency which was providing wound care for R1 at the time the wounds developed.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20221209132559

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE SENIOR HOME CARE	FACILITY NUMBER: 197608268
	VISIT DATE: 08/24/2023

NARRATIVE

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Regarding allegation: Staff did not seek medical attention for resident in a timely manner. It is alleged Responsible party had asked the administrator to call 911 and administrator did not call 911 and told responsible party to call the hospice nurse instead. R1 received services from Caremore Health per records reviewed from 6/15/22 to 10/17/22. On 10/17/22 Caremore Health physician provided a referral for hospice care. On 10/18/22 R1 initiate hospice care with Medplus Hospice Services. Interview conducted with hospice nurse revealed, R1’s representative was made aware that R1 would be provided comfort care for the existing diagnosis. Responsible party was also made aware that hospice services will end if R1 was send out to the hospital. Interview with administrator revealed all changes in condition were promptly reported to the hospice nurse and Caremore nurse when observed. On 11/3/22 nurse visited R1 due to shortness of breath and comfort care was provided. On 11/8/22 R1 hospice nurse contacted R1’s responsible party, during that called nurse learned that responsible party had requested facility staff to call 911. At that time nurse contacted 911 and R1 was transfer to the hospital. Due to R1 being on hospice care, a hospice nurse was providing care from 10/18/22 to 11/8/22 and both the facility staff and hospice nurse were following hospice protocols.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff placed resident on hospice care without resident's POA's approval. It is alleged R1 was placed on hospice without the power of attorney (POA)'s consent. Interview with POA revealed that due to not knowing much about hospice, POA refused when advice by administrator that R1 may need hospice care. POA "relented and agreed to hospice". POA acknowledge to singing consent forms for hospice initiation. On 10/17/22 Caremore health physician provided a referral for hospice evaluation. Interview conducted with administrator revealed, Caremore health requested a hospice evaluation. Administrator stated to have advice POA that R1 was declining, and a hospice evaluation may be necessary. Upon POA inquiring for recommendations of hospice agencies, administrator provided different hospice agencies choices. Interview with Hospice Nurse revealed that POA signed R1 into hospice care. Per documents reviewed on 10/18/22 POA signed the informed consent and treatment authorization for hospice services. On 11/8/22 POA signed a hospice revocation.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20221209132559

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE SENIOR HOME CARE	FACILITY NUMBER: 197608268
	VISIT DATE: 08/24/2023

NARRATIVE

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Regarding allegation: Staff did not ensure resident was fed. It is alleged facility staff did not ensure R1 was fed. Interviews conducted with residents revealed 3 out of 3 residents stated facility staff provide three meals and ensure they eat their meals, as well as provide additional options of meals when requested. Interviews with family members revealed facility ensures their family members eat by providing a meal the resident requested. Administrator also notifies family, who choose to bring something they know the resident likes. Interviews with staff revealed 3 out of 3 staff interviewed stated to provide meals to residents, to follow physician’s recommendations for meals, and to provide ensure drink when physician recommends as a substitute for a meal as needed.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff did not ensure resident was administered medications. It is alleged facility staff did not ensure R1's medications was administered. Interviews conducted with residents and family members revealed facility provides their medication as prescribed and had no concerns regarding medication provided. Interviews with staff revealed staff provide medication as prescribed and noted in a medication sheet. Per documents reviewed, On 10/18/22 power of attorney was notified there were no changes in medication by hospice nurse. On 11/7/22 hospice nurse visited R1 and discuss with POA the need for comfort medications. On 11/8/22 hospice nurse visited and informed POA of medications administer to R1 on that day. Medication logs for August 2022 to November 2022 were reviewed, staff initialed each dose provided per day, no refused or skipped medication were noted.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff did not ensure resident is involved with resident activities and Staff isolated resident in care. It is alleged staff did not ensure R1 joins the other residents in the dining hall or involved in resident activities and was always left alone. Interviews with residents and family members revealed residents spend time in the dining room, and facility staff either take residents on walks in the neighborhood or provide time in the backyard.
(CONTINUED ON LIC 9099C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20221209132559

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE SENIOR HOME CARE	FACILITY NUMBER: 197608268
	VISIT DATE: 08/24/2023

NARRATIVE

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Interviews with staff revealed residents like to spend time in the living room and in the back yard and are in their rooms only when they choose to have some quiet time. Documents reviewed revealed, that on 10/20/22 a hospice social worker visited the facility and observed R1 sitting in the TV room. On 11/3/22, R1 was observed sitting in a chair, awake and alert by hospice nurse.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff did not allow resident visitors. Responsible party was never allowed inside the facility until just recently. Interviews with residents and family members revealed, residents receive visits at the facility and have not been denied entry to the facility. Interviews with staff revealed visitors are allowed at the facility and there are different areas indoor and outdoor in the facility for families to visit the residents. Staff stated that in 2022 facility was allowing visitors and only asking families to self-assess for COVID symptoms prior their visit. Documents reviewed revealed, on 11/7/22 POA was present during a visit from hospice. Visitor log showed R1's representative visited on 9/15/22, 9/23/22, 10/7/22, 10/16/22, 10/19/22, 10/22/22, 10/26/22. Facility keeps a visitors log from 2021 to present.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Nino Navarro and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

LIC9099 (FAS) - (06/04)

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