198204494-11-16-2022-11-AS-MVAO-CLNSJ6-20221130125437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204494
Report Date: 11/16/2022
Date Signed: 11/16/2022 10:50:40 AM

Unsubstantiated

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
07/03/2020 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200703090616

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: 28	DATE:	11/16/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Executive Director/Administrator, Remon Pagels		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee did not bring changes in resident condition to the attention of the residents’ physician in a timely manner.

Questionable death.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (Amy Berggreen, Community Business Director) and was later met by Administrator (A2: Remon Pagels). The purpose of this visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations. A virtual 10-Day visit was conducted by (former) LPA Jennifer Jones on 07/06/20 (via telephone) with (then) Executive Director/Administrator (A1: Brian Larios) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.
During the televisit, LPA requested pertinent documents: Staff and Residents' rosters, Physician’s Report, Admissions Agreement, Identification and Emergency Information, Re-appraisals, and Medical Records for Resident #1. A separate investigation was conducted by the Department of Social Service Investigator (IB: Edward Hector) which included a review of medical, hospital, home health, and hospice records for Resident #1 including: interviews with facility staff, medical services staff, and witnesses. LPA/RA Ceniceros spoke to S1 to conduct a risk assessment. S1 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

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 11-AS-20200703090616

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: ATRIA PARK OF PACIFIC PALISADES	FACILITY NUMBER: 198204494
	VISIT DATE: 11/16/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding Allegation #1: this investigation revealed that Resident #1’s medical records from the hospital, home health agency, hospice care, and facility showed all three (3) agencies in communication with one another about Resident #1’s condition. Various medical records from six (6) different agencies [(three (3) home care services, two (2) offices of assigned doctors, and one (1) hospital)], listed the constant communication with Resident #1’s family (Daughter/Power of Attorney), facility staff, and assigned primary care physician. IB Investigator Edward Hector noted that medical records documented that Resident #1 had developed three (3) non-pressure wounds on the left, lower leg and received daily wound care by home health nurses. Prior to receiving care for the left leg wounds, Resident #1 had recently been discharged from home health services for a healed wound on the resident's right leg. Resident #1 was admitted to the hospital on 05/14/20 for poor circulation that caused open wounds. While the resident was in the hospital, the resident's physician warned the resident's family (Daughter/Power of Attorney) that amputation of the wounded leg was necessary or else sepsis would develop; however, the family (Daughter/Power of Attorney) opted for comfort and declined amputation. Resident #1 was discharged from the hospital on 05/18/20; and, the family agreed to Resident #1 returning to the facility on hospice - despite the doctor's recommendation of amputation. Medical records documented that Resident #1 had been under consistent care of registered nurses or hospital staff and all changes in the resident's condition were thoroughly communicated as well as to the resident's family (Daughter/Power of Attorney).

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Licensee did not bring changes in resident condition to the attention of the resident’s physician in a timely manner is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that Resident #1 was admitted to the facility on 12/26/17. A small sore was noticed on the resident’s leg on 04/16/20. Daily wound care by home health nurses began on 04/25/20 thru 05/06/20. During that time, the resident developed three (3) non-pressure wounds on the left, lower leg due to poor circulation. Resident #1 was admitted to the hospital on 05/14/20 because of poor circulation, which caused the wounds to open. Resident #1 had a skin integrity diagnosis before the sore developed; thus, it was not out of the ordinary for this resident to develop this wound. Resident #1's physician warned the family (Daughter/Power of Attorney) about sepsis without utilizing amputation; however, the resident’s family opted for comfortable measures instead. Medical records indicated that the family

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20200703090616

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: ATRIA PARK OF PACIFIC PALISADES	FACILITY NUMBER: 198204494
	VISIT DATE: 11/16/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Daughter/Power of Attorney) refused amputation and were advised of a potential result of a terminal illness. Resident #1 was discharged from the hospital on 05/18/20 and placed on hospice care and returned to the facility with the family's (Daughter/Power of Attorney) approval. Resident #1 passed away on 06/04/20 with a primary diagnosis of sepsis and a secondary diagnosis of non-pressure ulcer with necrosis of muscle.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Questionable Death is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Executive Director/Administrator, Remon Pagels.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3