197609007-11-16-2021-28-AS-SCOL-CCAUKP-20220307143925

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609007
Report Date: 11/16/2021
Date Signed: 11/16/2021 11:36:07 AM

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
07/27/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20210727121037

FACILITY NAME:	GLENDALE GARDEN CARE HOME		FACILITY NUMBER:	197609007
ADMINISTRATOR:	DEANON, IRENE		FACILITY TYPE:	740
ADDRESS:	405 CHESTER STREET		TELEPHONE:	(818) 640-2912
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91203
CAPACITY:	6	CENSUS: 5	DATE:	11/16/2021
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Romina DSouza - Caregiver in Charge		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility staff did not observe changes in resident's condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with caregiver Paulette Leyrit and explained the reason of the visit. Romina DSouza arrived a few minutes later.

The investigation consisted of the following: On 8/3/21 LPA conducted interviews with administrator, staff #1(S1), #2(S2), and residents #1(R1), #2(R2),#3(R3),#4(R4). LPA reviewed residents files and requested copies of staff/resident roster, physician's report, needs and care plan, emergency identification information, appraisal, caregiver notes, and medication sheets for R1,R2,R3,R4, and resident #5(R5). On 8/4/21 LPA attempted to contact R5's responsible party. On 8/19/21 LPAs Flores and Mora requested copies of the following documents: Narrative charting, identification and emergency information, Home health care field notes, medication profile, consent to treatment, propose plan of services, transfer and discharge information for resident #5, facility's visitor log for 7/18/21 to 8/13/21, vital caregiver's notes from 7/19/21 to 7/26/21, staff roster and staff schedule. (CONTINUED ON LIC 9099C)

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: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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 3

Control Number 28-AS-20210727121037

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: GLENDALE GARDEN CARE HOME	FACILITY NUMBER: 197609007
	VISIT DATE: 11/16/2021

NARRATIVE

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LPAs interviewed licensee and staff #4 and conducted interviews over the phone with hospice nurse and staff #3, attempted to conduct interview over the phone with staff #4 and resident #5's responsible party. On 10/7/21 LPA Flores requested Investigator Bureau (IB) to obtain medical records for R5. On 10/26/21 LPA Flores received documents from IB investigator Veronica Padilla.

The investigation revealed the following: Regarding allegation: Facility staff did not observe changes in resident's condition. It is alleged R5 was taken to ER on 7/24/21 after responsible party found R5 "slumped over" at the dining table during an unannounced visit. Responsible party asked staff to check his blood pressure and blood pressure and heart rate were low. On 8/3/21 LPA Flores reviewed R5's physician report, resident appraisal, hospital discharge, appraisal/needs and care plan and facility's notes. Appraisal/needs and care plan notes on socialization: "low blood count: monitor for any ill effects of blood transfusion on 6/30/21 and 7/12/21: being weak/feeling tired." Hospital discharge dated 6/30/21 notes R5 was seen for a medical procedure. Facility's notes showed R5 was taken by responsible on 7/12/21 for a medical procedure. On 8/3/21 LPA attempted to interview 4 residents at the facility but was not able due to cognitive skills. On 8/19/21 LPA reviewed facility's daily assessment on 7/24/21 there are no notes for R5 at 7:00am or during 2nd shift. Per administrator R5 was under home health care services and was visited twice a week for services, administrator was informed that R5 woke up around 10:00am and was assisted with a shower due to bowel movement. Staff #3 stated to not know what occur or regarding noticing changes in condition. 4 out 4 staff were aware of R5's health condition and procedures to take in case a change is observed. Hospice Nurse stated to be at the facility for another resident and was taking notes in dinning room when R5 was sitting at table and responsible party arrived and requested 911 be contact, and was taken by ambulance around 2:00pm. On 10/26/21 LPA Flores reviewed medical records and Hospital Patient Information Sheet notes R5.

Based on LPA's document review, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Romina DSouza lead caregiver and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210727121037

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: GLENDALE GARDEN CARE HOME	FACILITY NUMBER: 197609007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/17/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation... This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee will certify by LIC 9098 by 11/17/21 to ensure change in condition of all residents is observed, and will provide in service training to staff and submit documentation by 11//1921.
	8 9 10 11 12 13 14	Based on documents reviewed and interviews R5 was not observed for change in condition on 7/24/21 which poses an immediate health, safety, or personal rights violation for residents 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: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC9099 (FAS) - (06/04)

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