197608358-11-25-2024-28-AS-TVAO-DBLN45-20241203090720

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608358
Report Date: 11/25/2024
Date Signed: 11/25/2024 10:33:45 AM

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
02/09/2023 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230209133746

FACILITY NAME:	LA POSADA IN SAN DIMAS		FACILITY NUMBER:	197608358
ADMINISTRATOR:	LUCY PARKER		FACILITY TYPE:	740
ADDRESS:	1452 GOLDRUSH STREET		TELEPHONE:	(909) 599-2273
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	6	CENSUS: 5	DATE:	11/25/2024
		UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Graciela Martinez - Caregiver		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Resident in care was sexually assaulted
Resident sustained fracture while in care due to lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA Flores met with Graciela Martinez and explained the reason for the visit.

The investigation consisted of the following: On 2/10/23 LPA Mora conducted a health and safety check visit at the facility. On 2/15/23 Investigation Bureau assigned IB investigator Phillipe Miles as an assignment on this investigation. On 3/3/23 Investigation Bureau changed the assignment to a full investigation. On 2/7/24 a referral was submitted to our Nurse Consult Department. On 7/25/24 LPA Mora conducted a subsequent visit with IB investigators, additional documents pertaining the investigation were requested for resident #1(R1). On 9/20/24 LPA Mora conducted interviews with administrator and hospice representative. On 11/8/24 LPA Flores interviewed administrator over the phone. On 11/14/24 LPA Flores interviewed Power of Attorney (POA) over the phone. On 11/18/24 LPA Flores attempted interviews with current facility resident’s representatives. On 11/25/24 LPA Flores conducted a visit to deliver findings. (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: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

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-20230209133746

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: LA POSADA IN SAN DIMAS	FACILITY NUMBER: 197608358
	VISIT DATE: 11/25/2024

NARRATIVE

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The investigation revealed the following: Regarding allegation: Resident in care was sexually assaulted. It is alleged facility staff shave residents in their perineal area without consent. Interviews conducted with staff revealed, staff do not have a requirement to shave the residents in the perineal area while they are in care at the facility. Interview conducted with one family member revealed facility staff do not required to shave the resident in care or been asked to allow it. On 11/19/22 R1 was hospitalize due to a hip fracture. During the hospitalization R1’s POA requested a Sexual Assault Response Team (SART) exam to be given. However, after requesting hospital records there are no records to review. Per IB investigator hospital does not keep records of SART exam. Therefore, although the allegation may be true, there are no records, pictures, or statements to corroborate the allegation at this time.

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 fracture while in care due to lack of supervision. It is alleged R1 sustained a fracture after a fall from the bed while in care. On 11/19/22 R1 was hospitalized due to a femoral neck fracture to the hip. Interviews conducted and documents reviewed revealed the following: On 11/16/22 R1 was visited by hospice nurse and was noticed to have full range of motion on all extremities. On 11/17/22 staff were providing care to R1 in R1’s bed. Per staff, R1 kicked and batted while providing care. No signs of distress were noticed on 11/17/22. On 11/18/22 facility staff noticed signs of pain. Administrator contacted hospice agency and notified them of the change in condition. Hospice physician prescribed 500mg acetaminophen for pain. Administrator stated to have contacted R1’s POA to send R1 to the hospital due to change in condition. Per administrator, POA requested an x-ray prior sending R1 to the hospital. On 11/18/22 at 4:50pm a request from hospice was place for an x-ray. On 11/19/22, a mobile imaging agency visited the facility, and an x-ray was taken. X-ray results revealed R1 had an acute femoral neck fracture to the hip. On 11/19/22, R1 was send to the hospital per POA’s request. Per hospice communication log, administrator contacted hospice on 11/18/22 at 4:39pm to notified R1 is complaining of pain, acetaminophen 500mg was prescribed and family was notified. At 4:50pm POA contacted hospice to notified of new on set of moderate to severe pain, no falls were reported, and an x-ray was requested. On 11/19/22 hospice received x-ray results from mobile imaging. Results identified an acute femoral neck fracture to the hip. POA decided to hospitalize R1 seeking alternative treatment. Per hospice plan facility is to call hospice for “any changes in condition, medication, treatment, plan of care, and for any concerns”. (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: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230209133746

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: LA POSADA IN SAN DIMAS	FACILITY NUMBER: 197608358
	VISIT DATE: 11/25/2024

NARRATIVE

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Power of Attorney and Advance health care directive was given to R1’s family member and signed on 3/16/2012. After document review there is no evidence R1 sustained falls, was a fall risk resident, or had history of falls or previous fractures. Although there is a possibility the incident occurred on 11/17/22 due to R1's kicking, there were no signs of pain noticed by staff until 11/18/22. There are no records indicating R1 sustained a fall. Upon, R1's change in condition notice of pain facility staff reached out to hospice as directed by hospice plan and steps to provide care were noted. Hospice followed POA’s request and discharge R1 from hospice, upon POA requesting to send R1 to the hospital for alternative care. R1 was send to the hospital on 11/19/22, the same day the results for the fracture were observed. Therefore, although the allegation may be true there is not enough evidence that the facility was neglectful at this time.

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 Lorraine Lopez 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: 11/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC9099 (FAS) - (06/04)

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