197803648-3-14-2024-28-AS-RORN-D3QU8N-20240326152149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803648
Report Date: 03/14/2024
Date Signed: 03/14/2024 11:48:48 AM

Unsubstantiated

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
10/04/2023 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231004142452

FACILITY NAME:	GENESIS MANOR II		FACILITY NUMBER:	197803648
ADMINISTRATOR:	GERRY MARKIE		FACILITY TYPE:	740
ADDRESS:	2123 AQUINAS AVE.		TELEPHONE:	(909) 262-9802
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 5	DATE:	03/14/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Alina Hendrick- Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident in care sustained pressure injury due to staff's neglect.
Staff did not ensure resident's wound care needs were properly met.
Staff prevented home health agency staff from performing their duties.
Uncleared staff allowed to work in the facility.
Facility did not have a qualified administrator.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of continuing the investigation regarding the above-mentioned allegations, and to deliver findings. LPA Maldonado met with Administrator, Alaina Hendrick, and explained the purpose for the visit.

On 10/05/2023, LPA Maldonado made an initial visit at the facility for the purpose of conducting a health and safety inspection. During the visit, LPA obtained a copy of the resident/staff rosters, conducted a tour of physical plant and common areas with staff Elyssa Markie, and obtained the following documents for Residents# 1-6 (R1-R6): Facesheet, Physician's Report, Needs and Services Plan, and Hospice Care Plans. LPA observed food supplies, resident rooms, and observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns during the visit. During the visit, LPA discovered that all listed staff on the facility roster are currently associated, and current Administrator Certificate# 6015601740 for Alaina Hendrick is available and posted with expiration date of: 07/18/2024. (Report continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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 4

Control Number 28-AS-20231004142452

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: GENESIS MANOR II	FACILITY NUMBER: 197803648
	VISIT DATE: 03/14/2024

NARRATIVE

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The following allegations were assigned to be investigated by the licensing agency's Investigation Bureau (IB) investigator, Heydi Bendana: 1.) Resident in care sustained pressure injury due to staff's neglect. 2.) Staff did not ensure resident's wound care needs were properly met.
Investigator Bendana's investigation consisted of the following: Interviews conducted with Administrator Alaina Hendrick (S1), Staff #2-3 (S2-S3), Witnesses #1-4 (W1-W4), which consists of Resident#1's (R1) responsible party (W1), hospice physician (W2), primary care physician (W3), and home health case worker (W4). Investigator Bendana also attempted to interview residents, but was unable to due to cognitive impairment. The following documents for R1 were also reviewed: facility file/documentation including hospice care plan and relevant documents, wound progress reports dated: 9/21/23, 9/28/23,10/12/23, and 10/19/23. The investigation revealed the following:

Regarding allegation: Resident in care sustained pressure injury due to staff's neglect.
It is alleged that due to staff neglect, R1 sustained a Stage 2 pressure wound, which quickly deteriorated and turned to a Stage 4 pressure wound, and R1's bone became visible. Per hospice and home health records obtained by Investigator Bendana, it was discovered that R1 was admitted to the facility on home health services due to pressure wounds, and was receiving services to provide wound care. Per Investigator Bendana's interviews conducted, (3) of (3) staff denied neglecting R1's care resulting in a pressure wound rapidly deteriorating. Staff stated that S1 sought better care for R1 when they noted R1's wounds were not healing properly due to the care provided from the initial home health agency that was providing care. Per witness interviews, (4) of (4) witnesses denied the facility neglecting the resident's care resulting in a pressure wound deteriorating. Per W2, due to the resident's current health condition, it was "almost impossible" to prevent R1 from to sustaining pressure wounds, regardless of how well the wounds were being cared for and how often R1 was being repositioned. Per W4, hospice staff reported to W4 that facility staff were providing "excellent care" to R1. Per R1's hospice care plan, R1 required frequent repositioning to assist in the healing of the pressure wounds and there is no indication that the pressure wounds ever deteriorated to a stage 4. Therefore, this allegation is Unsubstantiated.

Regarding allegation: Staff did not ensure resident's wound care needs were properly met.
It is alleged that facility staff did not meet R1's wound care needs, while R1 presented with stage 2 pressure wounds, which quickly deteriorated and resulted in stage 4 pressure wounds.

(Report continued on LIC9099-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20231004142452

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: GENESIS MANOR II	FACILITY NUMBER: 197803648
	VISIT DATE: 03/14/2024

NARRATIVE

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Per investigator Bendana’s interviews conducted, (3) of (3) staff denied not meeting R1's wound care needs. Staff stated that they repositioned R1 frequently as noted in R1’s care plan and followed R1’s wound care plan. They also stated that S1 sought better care for R1 when they noted R1's wounds were not healing properly due to the care provided from the initial home health agency that was providing care. Per witness interviews, (4) of (4) witnesses denied the facility staff not meeting the resident's wound care needs. Per W2, due to the resident's current health condition, it was "almost impossible" to prevent R1 from to sustaining pressure wounds, regardless of how well the wounds were being cared for and how often R1 was being repositioned. Per W4, hospice staff reported to W4 that facility staff were providing "excellent care" to R1. Therefore, this allegation is Unsubstantiated.

During today's visit, LPA Maldonado, continued the investigation regarding the following allegations:

4. Staff prevented home health agency staff from performing their duties.

5. Uncleared staff allowed to work in the facility.

6. Facility did not have a qualified administrator.

LPA also obtained personnel records for Administrator, Alaina Hendrick, and conducted interviews with Staff#1-6 (S1-S6), and Home Health LVN (LVN). LPA attempted to interview Residents#1-5 (R1-R5), but was unable to due to cognitive impairment.
The investigation revealed the following:

Regarding allegation: Staff prevented home health agency staff from performing their duties.
It is alleged that a facility staff, who is not the administrator of the facility, informed a home health agency that they were not allowed to go to any of their licensed facilities- disrupting the care of residents who reside in this home. (6) of (6) staff interviewed denied the allegation, stating that home health has never been denied entry to this facility, to provide the services needed. Per interview with LVN, staff of this facility never denied home health entry to this facility, to provide services to a resident. (5) of (5) residents could not corroborate the allegation. Therefore, this allegation is Unsubstantiated.

Regarding allegation: Uncleared staff allowed to work in the facility.
It is alleged that a home health LVN was allowed to work at the facility without appropriate criminal background clearance and association to the facility.

(Report Continued on LIC9099-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20231004142452

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: GENESIS MANOR II	FACILITY NUMBER: 197803648
	VISIT DATE: 03/14/2024

NARRATIVE

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After review of the Facility Personnel Report Summary and the Staff Roster, it was noted that all staff have appropriate criminal background clearance and are associated to the facility. (6) of (6) staff interviewed denied the allegation and stated that LVN never worked at the facility as facility staff. LVN only provided home health services to residents. Staff also stated that new employees are fingerprint cleared and associated prior to working at the facility. (5) of (5) residents could not corroborate the allegation. Per interview with LVN, the allegation was denied and LVN stated to have never been employed as facility staff by the Licensee.

Regarding allegation: Facility did not have a qualified administrator.
It is alleged that a home health agency's LVN was allowed to work as an interim administrator for this facility, without having appropriate certification. (6) of (6) staff interviewed denied the allegation and stated that LVN has never worked as a staff or administrator for this facility. (5) of (5) residents interviewed could not corroborate the allegation. Per interview with LVN, the allegation was denied. LVN stated that LVN has never been employed by the facility Licensee and has never worked as a staff/administrator for this facility. Per staff roster and Facility Personnel Report, LVN is not listed as a staff at this facility and is not associated. After review of Administrator personnel records, Alaina Hendrick is the listed Administrator for this facility with Certificate# 6015601740 expiration date: 07/18/24 and has met the appropriate qualifications for Administrator.

Based on LPA's observations, records review, and interviews held: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Per California Code of Regulations, Title 22, no deficiencies were observed or cited.
Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC9099 (FAS) - (06/04)

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