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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608449
Report Date: 06/15/2021
Date Signed: 06/15/2021 11:30:56 AM



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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2021 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20210610115741
FACILITY NAME:SUPERIOR CARE HOMEFACILITY NUMBER:
197608449
ADMINISTRATOR:EMMA L. APOLINARIOFACILITY TYPE:
740
ADDRESS:44856 33RD STREET WESTTELEPHONE:
(661) 998-4364
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 4DATE:
06/15/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Emma ApolinarioTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility staff did not seek timely medical care for resident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Patrick Shanahan, Angela Panushkina, and Melissa Ruiz arrived at the facility in response to the above mentioned allegation. At 9:45 am, LPAs were able to tour the facility and began interviews with the administrator, staff and residents.

At 10:00 AM, the administrator stated that Resident 1 (R1), had a fall at about 1:00 AM in R1's room. The administrator, her husband and staff assisted R1 up and placed R1 in bed. The administrator confirmed that there was redness and swelling but did not think anything of it. The administrator continued to state 911 was not called until the next day at about 8:00 AM or 9:00 AM because the administrator wanted to inform R1's responsible party.

Based on staff and resident interviews, this allegation is deemed to be SUBSTANTIATED at this time. Exit interview conducted, deficiencies cited and report issued.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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 2
Control Number 31-AS-20210610115741
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUPERIOR CARE HOME
FACILITY NUMBER: 197608449
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2021
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care Services. 9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident’s health, including a apparent life-threatening medical crisis.
This requirement was not met as evidenced by
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Administrator agrees to provide training to staff on when to call 9-1-1. Sign-in sheet and training topic will be submitted.
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Based on interviews and record review, the administrator did not obtain timely medical care for R1, which posed an immediate risk to the health and safety of residents in care.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2