198204494-4-20-2022-11-AS-MVAO-CDUP39-20220426105708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204494
Report Date: 04/20/2022
Date Signed: 04/20/2022 12:56:30 PM

Substantiated

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 DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/20/2020 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20200220112554

FACILITY NAME:	ATRIA PARK OF PACIFIC PALISADES		FACILITY NUMBER:	198204494
ADMINISTRATOR:	PENA, ADAM		FACILITY TYPE:	740
ADDRESS:	15441 W SUNSET BLVD		TELEPHONE:	(310) 573-9545
CITY:	PACIFIC PALISADES	STATE: CA	ZIP CODE:	90272
CAPACITY:	60	CENSUS: 37	DATE:	04/20/2022
		UNANNOUNCED	TIME BEGAN:	11:23 AM
MET WITH:	Amy Bergreen		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

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Resident developed a pressure injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the above facility. . LPA spoke with staff via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to deliver findings on the allegations listed above and was allowed entry to the facility.

The investigation consisted of the following: On 2/20/2020 LPA conducted initial visit and met with Administrator. LPA reviewed and requested copies of facility records. LPA did a health and safety check and toured the entire facility with administrator. LPA received the following records: staff roster, client roster, time sheet from 2/1/2020 to 2/15/2020, Physicians reports, admissions agreements, hospice/home health notes, medication logs, emergency and ID information. medication administration records, hospice care info for five residents. LPA also requested resumes and staff training for staff 1-staff 5, administrator certificate, daily shift notes for January 2020 and February 2020, house rules and activity schedules. LPA conducted a review of the Investigation Branch’s findings.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

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-20200220112554

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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: ATRIA PARK OF PACIFIC PALISADES	FACILITY NUMBER: 198204494
	VISIT DATE: 04/20/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Resident Developed a pressure injury while in care.

It is alleged that resident developed pressure injuries while in facilities care due to staff neglect. IB Investigator Jose Santana conducted an investigation into the allegations which consisted of both records review and interviews. On 1/8/2020 Resident 1 (R1) was discharged from hospital on 1/8/2020 with notes stating resident had blanchable redness to coccyx and inner gluteal region. R1 entered facility on 1/8/2020. An initial assessment was conducted of their care needs and it was noted by facility staff on 1/9/2020 that resident did not require any skin care. On 1/10/2020 Doctors Choice home health visited R1 at facility to conduct an assessment and noted a stage 2 pressure injury on right buttock. Physician gave Doctors Choice home health a wound care order for treatment. Facility noted R1’s visit with Doctors Choice home health but did not have a report. It was stated during interview by S1 that facility would follow-up with Comfort choice home health, but a review or facility records does not show any documentation regarding follow-up. On 1/10/2022 R1 was admitted to St. John’s Health Center for another diagnosis and home health treatment stopped. R1 returned to facility on 1/16/2020 and home health services with Doctor’s Choice were not resumed. On 2/3/2020 a “blood blister” was found by facility staff on R1’s sacrum and Doctors Choice Home health was contacted. Doctors Choice home health resumed their treatment of R1 on 2/3/2020 and on 2/4/2020 it was noted that R1 had a stage 2 pressure injury on their mid-lower back/sacrum with a recommended wound treatment and a note to turn resident every two hours and not have them sit for too long. On 2/10/2020 the “blood blister” started to break open and Doctors Choice home health had not visited R1 since 2/4/2020. Another home health service was requested and after their assessment of an unstageable pressure injury on R1’s sacrum, primary care physician for R1 was contacted and recommended R1 be sent to hospital. R1 entered hospital on 2/12/2020 and was diagnosed with three pressure injuries, redness to heals, one pressure injury on right hip and unstageable pressure injury on right sacrum.

Based on observations, interviews, and record review(s), the preponderance of evidence standard has been met. On 2/12/2020 R1 was admitted to St. Johns Health Center and present during admission were three pressure injuries: redness to heels, one pressure injury on right hip and unstageable pressure injury on right sacrum.

Records and interviews indicate that there was a break in home health coverage from 1/16/2020 when R1 returned from hospital to 2/3/2020 when “blood blister” was found by facility staff. Therefore, the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D.

An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1)

Exit interview conducted, appeal rights were discussed, and a copy of this report and appeal rights was provided to Business Director Amy Burgreen.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200220112554

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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: ATRIA PARK OF PACIFIC PALISADES	FACILITY NUMBER: 198204494
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/21/2022 Section Cited HSC 1569.49(c)(1)	1 2 3 4 5 6 7	Civil Penalty: Any violation that the department determines resulted in the injury or illness of a resident.	1 2 3 4 5 6 7	Licensee will submit written plan detailing how to ensure residents are provided with required services via fax by POC due date.
	8 9 10 11 12 13 14	It was observed through records review and interview that on 2/12/2021 Resident 1 was admitted to hospital with pressure injuries. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 05/11/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in all Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodation, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will complete a staff training on observation, documention, reporting and seeking medical/Home Health services in a timely manner. Submit in writting plan for training and sign in sheet as verification via fax by POC due date,
	8 9 10 11 12 13 14	It was observed through records review and interview that on 2/12/2021 Resident 1 was admitted to hospital with pressure injuries. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

LIC9099 (FAS) - (06/04)

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