197609123-12-20-2022-11-AS-MVAO-CMC2SY-20221221163957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609123
Report Date: 09/28/2022
Date Signed: 12/20/2022 02:34:29 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/08/2022 and conducted by Evaluator Stephanie Cifuentes

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220208101955

FACILITY NAME:	BENTLEY SUITES BY SERENITY CARE HEALTH		FACILITY NUMBER:	197609123
ADMINISTRATOR:	RENEL CABRAL		FACILITY TYPE:	740
ADDRESS:	851 4TH STREET		TELEPHONE:	(213) 478-0800
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90403
CAPACITY:	0	CENSUS: 0	DATE:	09/28/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Facility staff not available		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident developed multiple pressure injuries while in care
Staff did not ensure a resident consumed an appropriate amount of fluids while in care
Staff did not address a resident's change in medical condition

INVESTIGATION FINDINGS:

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Licensing Program Manager (LPM) Stephanie Cifuentes attempted to conduct an unannounced subsequent complaint visit to the facility. Facility closed on 8/26/2022 so findings could not be delivered as there was no authorized agent available for a signature. The administrator on file for Bentley Suites was Renel Cabral, however, at the time of this complaint, Mr. Renel Cabral had not been administrator of the facility for some time. Per records received during the course of this investigation, Mona Alcazar was administrator of the facility

The investigation consisted of the following:
On 02/08/2022 LPA Stephanie Cifuentes toured the inside and outside grounds of the facility to conduct a healthy and safety check. LPA requested and received copies of the following: Client Roster, staff roster, administrator certificate, staff personnel records, training as well as ID and emergency information, physicians’ reports, admissions agreement, resident appraisal and all medical records to include any hospital records for Resident #1.
Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

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 11-AS-20220208101955

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH	FACILITY NUMBER: 197609123
	VISIT DATE: 09/28/2022

NARRATIVE

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A separate investigation was conducted by the Department of Social Services Investigator Tiffany Brunelli that included a review of medical records, interview with witnesses, facility staff and medical services staff.

INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Resident developed multiple pressure injuries while in care

It is alleged that resident developed pressure injuries while in facilities care due to staff neglect. The department conducted an investigation into the allegation which consisted of both a records review and interviews. From medical records it was determined that on 1/3/2022 resident 1(R1) was admitted to Providence Saint John’s Health Center for acute hypoxemic respiratory insufficiency. R1 was released from the hospital on 1/9/2022 with an order for home health services from Epic Homecare. A doctor’s order was given to provide wound care for R1 on a stage 2 decubitus ulcer and to check nutritional and hydration status. Epic Home Care visited on R1 on 1/10/2022 and on 1/17/2022. Home care records for nurse 1 (N1) noted R1’s decubitus ulcer was healed on 1/17/2022 and client was discontinued from wound care. On 1/19/2022 N1 assessed R1 and found them to have a cough, decreased breathing sounds and low oxygen but no fever. After a call to family, R1 was hospitalized at Providence Saint John’s Health Care Center and diagnosed with COVID-19. R1 was released to facility on 1/20/2022. R1 was visited by N1 on 1/21/2022 and 1/24/2022. Medical records from home health nurse note that skin checks were conducted, and no pressure injuries found. On 1/28/2022 R1 was admitted to the emergency room at Providence St. John’s Health Care Center. Records indicate R1 was admitted with 5 pressure injuries: unstageable pressure ulcer of right heel, unstageable pressure ulcer of left heel, unstageable pressure injury of right sacral spine, unstageable pressure injury of left sacral spine and a stage 1 pressure injury on left buttock. IB Investigator Tiffany Brunneli interviewed facility staff 1 (S1) on 2/16/2022. S1 indicated they changed R1’s socks before they were picked up by family on 1/28/2022 and did not observe any pressure injuries or blackening of skin on heals. The department also interviewed Staff 2 (S2), Staff 3 (S3), Staff 4 (S4) and (N1) who all stated they saw no pressure injuries on R1 between 1/20/2022 and 1/28/2022.

Based on observations, interviews, and record review(s), the preponderance of evidence standard has been met. Records and interviews indicate there was a lack of care/supervision that led to neglect of resident and hospitalization for five pressure injuries, Therefore, the allegation, is found to be SUBSTANTIATED.

Continued on 9099-C

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220208101955

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH	FACILITY NUMBER: 197609123
	VISIT DATE: 09/28/2022

NARRATIVE

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Allegation: Staff did not ensure a resident consumed an appropriate amount of fluids while in care
It is alleged that facility did not give resident enough liquids to drink, and resident became dehydrated. The department conducted an investigation into the allegation which consisted of both a records review and interviews. From medical records it was determined that on 1/3/2022 and again on 1/28/2022 R1 was hospitalized at Providence St. John’s Health Care Center and diagnosed with intravascular dehydration. Records received through the course of the investigation show that family of R1 sent an email to facility recapping a call that occurred with facility staff S7. The email outlined the need for R1 to drink 64 ounces a day. It was noted by witness 1 (W1) that the facility was giving R1 about 24 ounces a day or 1 cup of liquid with each meal, and several times the cups from the previous meal appeared untouched. IB Investigator Tiffany Brunneli interviewed facility staff S1 on 2/16/2022. S1 stated that from 1/20/2022 to 1/28/2022 R1 needed to be fed because they were so weak, R1 did not eat as much as they had not appetite, and R1 did not drink as much juice but did drink water.

Based on observations, interviews, and record review(s), the preponderance of evidence standard has been met. Records and interviews indicate there was a lack of care/supervision that led to neglect of resident and hospitalization intravascular dehydration. Therefore, the allegation, is found to be SUBSTANTIATED.

Continued on 9099-C

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220208101955

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH	FACILITY NUMBER: 197609123
	VISIT DATE: 09/28/2022

NARRATIVE

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Allegation: Staff did not address a resident's change in medical condition
It is alleged that staff did not have resident seen by a doctor or change plan of care for resident when they noted a change in condition during isolation period. The department conducted an investigation into the allegation which consisted of both a records review and interviews. Medical records indicate on 1/28/2022 R1 was admitted to the emergency room at Providence St. John’s Health Care Center. R1 was admitted with 5 pressure injuries, four of which were unstageable; intravascular dehydration and moderate protein calorie malnutrition. IB Investigator Tiffany Brunneli interviewed facility staff on 2/16/2022, 3/29/2022, 6/14/2022, and 6/16/2022. Of the 6 staff interviewed, 5 out of the 6 stated that R1 was not eating as much or was weak. The department requested facility records, but until the closure of the investigation no records were provided that indicated a plan of care was implemented to address R1’s change in condition nor were any records provided to indicate facility informed MD or family of resident R1’s change in medical condition.

Based on observations, interviews, and record review(s), the preponderance of evidence standard has been met. Records and interviews indicate there was a lack of care/supervision that led to neglect of resident and hospitalization for intravascular dehydration. Therefore, the allegation, is found to be SUBSTANTIATED.

Based on observations, interviews, and record review(s), the preponderance of evidence standard has been met and the allegations found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8 the following regulations would normally be cited however, due to the closure of the facility citations could not be issued: 87468.2(8) Additional Personal Rights of Residents in Privately Operated Facilities for neglect of R1, which led to pressure injuries; 87466-Observation of the Resident for not ensuring to observe R1 for changes in health condition and reporting them to R1’s authorized representative and doctor in a timely manner; 87465(a)(1) Incidental Medical and Dental Care for not ensuring R1 received timely medical attention and; 87405(h)(5) Administrator-Qualifications and Duties for administrator not ensuring services appropriate to R1’s physical and mental well-being and needs were provided.

An exit interview could not be completed due to facility closure.

SUPERVISOR'S NAME: Benita Yates	TELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC9099 (FAS) - (06/04)

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