198204950-6-26-2024-11-AS-JHAD-D7ALWS-20240718090733

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 06/20/2024
Date Signed: 06/26/2024 10:36:58 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/03/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230803103418

FACILITY NAME:	CARSON SENIOR ASSISTED LIVING		FACILITY NUMBER:	198204950
ADMINISTRATOR:	SHOLOM GOLDMAN		FACILITY TYPE:	740
ADDRESS:	345 EAST CARSON STREET		TELEPHONE:	(310) 830-4010
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	230	CENSUS:	DATE:	06/20/2024
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	03:37 PM

ALLEGATION(S):

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Staff did not ensure residents dentures were clean.
Staff did not ensure residents clothes were clean.
Due to staff neglect resident sustained pressure injuries.
Staff did not safeguard residents' personal property.
Staff did not contact authorized representative when resident became unresponsive.
Staff did not notice residents change in condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Administrator (A1: Ginger Enriquez). The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations.

The investigation consisted of the following: A complaint visit for health and safety check of residents in care was on 08/10/23, 04/04/24, and 06/20/24. LPA requested pertinent documents related to the allegations mentioned above: Residents’ Roster (dated: 08/10/23), Register of Facility Residents LIC 902 (dated: 06/21/21), Staff Roster & Work Schedules (date: 08/10/23), Admissions Agreement (dated 03/11/21), Physician’s Report (dated 12/13/22), Preplacement Appraisal Information LIC 603 (dated 03/11/22), Appraisal/Needs Services Plan LIC 625 (dated: 08/11/21), Identification and Emergency Information LIC 601 (dated: 03/11/21), Personal Care Log (dated 05/24/23 - 0710/23), Caregiver Notes (dated: 04/4/23 -07/10/23), One Hour Monitoring Log (dated: 04/01/23 -07/10/23)
(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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 8

Control Number 11-AS-20230803103418

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 06/20/2024

NARRATIVE

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Two-Hour Incontinent Check Log (dated: 05/01/23-07/10/23), Daily Body Check Log (dated: 02/02/22 - 07/10/23), and Medication Administration Records (dated 05/01/23 - 07/31/23) for Resident #1. A review of Harbor UCLA Medical Center (HUCLAMC) hospital records (dated 07/14/23) and Providence Hospice, Inc. Communication Log (dated: 12/11/22 – 07/19/23), Dental Records, Home Health Records. Interviews of family representatives (W2-W9), home health agency administrator (W1) facility staff (A1, S1-S3), and residents (R2-R10).

INVESTIGATION REVEALED THE FOLLOWING: According to Identification and Emergency Information LIC 601 (dated: 03/11/21) and Admission Agreement (dated: 03/11/21) Resident #1 (R1) was a former Driftwood Nursing Center resident who was admitted to Carson Senior Assisted Living on 03/11/21. (R1) was in the care of Concise Home Health Service from (03/03/21 through 12/10/22) and Providence Hospice, Inc. from (12/11/22 through 07/19/23). The Certificate of Death (dated: 04/10/24) indicated the cause of death was Cardiorespiratory Arrest on 07/25/23.

Allegation #1: Staff did not ensure residents dentures were cleaned.

In the complaint, the facility staff is accused of not having resident #1 (R1)'s denture cleaned. A detailed explanation of this issue was not provided by the complainant.

On 04/04/24 between 10:30 am to 03:00 pm, the Department interviewed (R1)’s family representative (W2) and reported concerns that (R1)’s dentures were always missing or lost. (W2) explained that (R1) had partial dentures as it was probably not cleaned regularly as it has gone missing.

On 04/04/24 between 8:30 am to 03:30 pm, the Department interviewed (A1) and staff# 1 -#3 (S1-S3) denied the allegation. (A1 and S1) reported that (R1) wore partial dentures that were cleaned whenever they were not missing. (S1-S3) have reported there were occasions when (R1)’s dentures were discovered wrapped in tissue and disposed in (R1)’s wastebasket. (S3) claimed to have found it a couple of times in the wastebasket mistakenly disposed of by (R1). (A1-S1) claimed the facility had On-Site Dental Care to perform oral hygiene care on (R1) as indicated on progress notes (07/13/22; 08/22/22; 09/22/22,10/27/22; 12/06/22; 02/16/23).

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 11-AS-20230803103418

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 06/20/2024

NARRATIVE

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According to Providence Hospice, Inc. Communication Log (dated: 12/11/22 – 07/19/23), notes indicated on 01/21/23, the hospice team spoke with (W3) and requested dentures for (R1). (W3) indicated (R1) lost denture two years back. Hospice scheduled (R1) for an oral X-ray on 02/16/23 was incomplete due to (R1) not willing to cooperate and (W3) was notified.

On 04/04/24 between 09:00 am to 02:22 pm, the Department interviewed (9) out of (9) residents #2 - #10 (R2-R10) who had no issues with oral dental care. (R2-R10) confirmed that the facility provided residents who had no dental coverage on-site dental care.

On 04/04/24 between 10:30 am to 03:00 pm, the Department interviewed family representatives (6) out of (6) witnesses #4 - #9 (W4-W9) claimed to have no issues with this matter. (W4-W9) were aware that on-site dental care was provided by the facility and found the service to be adequate and convenient for the residents in care. Based on the information collected, there is not enough evidence to corroborate the allegation mentioned above.

Allegation #2: Staff did not ensure residents clothes were clean.
Allegation #4: Staff did not safeguard residents’ personal property.

It is alleged that resident #1 (R1) was seen often in dirty clothes and that (R1) was seen not in clothes that (R1) had ownership of. The complainant reported (R1) was seen often in dirty clothes and clothes that did not belong to (R1). The complainant claimed (R1)'s own clothes had (R1)’s name on them but (R1) was often seen in clothes that did not belong to (R1). The complainant did not have further details on these allegations.

On 04/04/24 between 8:30 am to 03:30 pm, the Department interviewed (A1) and staff# 1 -#3 (S1-S3) all refuted these allegations. (A1 and S1) stated that (R1) was seen by a hospice aide twice weekly for dressing and grooming a part of (R1)’s daily routine. Maintaining good personal hygiene is vital to preventing ill health. (A1) and (S1-S3) expressed that (R1) required daily changes as (R1) was incontinent and would often soil clothing. (S1-S3) claimed that (R1) was only provided three outfits that would only last a few days. While clothing supplied by family members was laundered, (R1) will often be seen in donated clothing pieces. (S1-S3) claimed the clothing never appeared dirty and that donated clothing or recycled garments can never replace the appearance of new clothing.
(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 11-AS-20230803103418

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 06/20/2024

NARRATIVE

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On 04/04/24 between 10:00 am to 10:30 am, the Department interviewed hospice administrator witness #1 (W1) reported that (R1) was never seen in dirty clothing. (W1) claimed that a hospice aide assisted with dressing and grooming needs for (R1) twice a week. (W1) stated that her hospice team is mandated reporters, and if an act of neglect is observe it would be reported.

On 04/04/24 between 09:00 am to 02:22 pm, the Department interviewed (9) out of (9) residents #2 - #10 (R2-R10) all claimed not to have concerns with their clothing appearance nor had issues with clothing not being safeguarded by staff.

On 04/04/24 between 10:30 am to 03:00 pm, the Department interviewed family representatives (6) out of (6) witnesses #4 - #9 (W4-W9) reported to have no issues or concerns and that residents were found in presentable conditions and appearance in clothing when visits were conducted at the facility.

A review of Providence Inc. Communication Log (dated: 12/11/22 – 07/19/23) revealed hospice aides assisted weekly with (R1)’s dressing and grooming. A review of facilities Caregiver Notes (dated: 04/04/23 – 07/10/23), One Hour Monitoring Log (dated: 04/01/23 - 07/10/23), Daily Body Check Log (dated: 02/02/22 – 07/10/23), Two Hour Incontinent Check Log (dated: 05/01/23 – 007/10/23) and Personal Care Log (dated: 05/24/23 -07/10/23) revealed (R1) is be assisted daily by staff self-care needs accordingly. Based on the information gathered, there is not enough sufficient evidence to corroborate the allegations mentioned above.
Allegation #3: Due to staff neglect resident sustained pressure injuries.

The complainant alleged due to facility staff negligence resident #1 (R1) sustained pressure injuries. The complainant indicated (R1) was receiving wound care and was uncertain about what stage of the wound. The staff failed to change the bandages promptly, resulting in further pressure injuries.

Hospital records from Harbor UCLA Medical Center (dated: 07/14/23) indicated (R1) was admitted for general weakness and unresponsive. Medical records revealed (R1) sustained Coccyx Stage 3 pressure injury 3.5cm x 1.5 cm x 0.2 cm. Investigation revealed (R1) was admitted to Carson Assisted Living from Driftwood Nursing Center on 03/11/21. (R1) was under home health care with multiple home health agencies from (03/03/21 through 12/10/22) with a wound plan. (R1) continued wound care under Providence Hospice, Inc. from (12/11/22 through 07/19/23).
(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 11-AS-20230803103418

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 06/20/2024

NARRATIVE

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Providence Hospice, Inc. Communication Logs (dated: 12/11/22 – 07/19/23) revealed (R1) received continued wound care as noted in the progress notes. On 07/06/23, a wound assessment and treatment of Coccyx pressure ulcer wound is now a Staged 3. The treatment plan included three (3) times a week gauze and Hydrocolloid dressing or as needed or soiled was communicated.

On 04/04/24 between 8:30 am to 03:30 pm, the Department interviewed (A1) and staff# 1 -#3 (S1-S3) all contested negligence played a role in (R1)’s care. (A1 and S1) stated when it came to (R1)'s wounds were treated by hospice medical professionals. (A1-S1) claimed the facility staff was only responsible for (R1)’s non-medical care since the facility is a non-medical care facility. (A1 and S1-S3) all stated that although they are not trained medical professionals, the facility staff is trained to take care of the residents and supervise them. (A1) stated bandages that are wet or soiled are changed by hospice only. (S1-S3) claimed Daily Body Checks, Two-Hour Incontinent Checks, and One-Hour Monitoring Checks were performed on (R1). (S1-S3) reported Caregiver Notes and Personal Care Logs as a means of communicating with staff regarding the resident's conditions verified that (R1) was receiving adequate care daily.

On 04/04/24 between 10:00 am to 10:30 am, the Department interviewed hospice administrator witness #1 (W1) who reported that (R1) was under a wound care plan. Wound care treatment services continued with Providence Hospice, Inc. even after (R1) was discharged from (HUCLAMC) and was admitted to Rosecrans Care Center on 07/15/23. (W1) claimed the Carson Senior staff were not neglectful in (R1)’s care. (W1) found the facility staff was diligent, attentive, and responsive when it came to (R1)’s health care needs.

On 04/04/24 between 09:00 am to 02:22 pm, the Department interviewed (9) out of (9) residents #2 - #10 (R2-R10) and reported the facility would act accordingly and immediately attend to the resident’s needs.

On 04/04/24 between 10:30 am to 03:00 pm, the Department interviewed family representatives (6) out of (6) witnesses #4 - #9 (W4-W9) observed the facility staff to provide the appropriate level of care for residents and denied neglect or lack of care of residents.

A review of Providence Inc. Communication Log (dated: 12/11/22 – 07/19/23), Concise Home Health Services Records (date: 03/12/21), Efficient Home Health Services, Inc Records (date: 07/13/21), and facilities’ Caregiver Notes (dated: 04/04/23 – 07/10/23), One Hour Monitoring Log (dated: 04/01/23 - 07/10/23),
(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 11-AS-20230803103418

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 06/20/2024

NARRATIVE

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Daily Body Check Log (dated: 02/02/22 – 07/10/23), Two Hour Incontinent Check Log (dated: 05/01/23 – 007/10/23) and Personal Care Log (dated: 05/24/23 -07/10/23) verified that (R1) was provided the appropriate wound care assistance. Based on the information collected, there is not enough evidence to support the allegation mentioned above.

Allegation #5: Staff did not contact authorized representative when resident became unresponsive.

The details of the complaint alleged that facility staff did not contact the authorized representative when resident #1 (R1) became unresponsive. The complainant reported that (R1)’s authorized representative was not contacted, and a non-Power of Attorney was contacted instead on 07/10/23 by staff when (R1) was hospitalized.

On 04/04/24 between 8:30 am to 03:30 pm, the Department interviewed administrator #1 and staff #1 (A1 and S1) who claimed this accusation is not correct. (A1 and S1) explained that (R1) was under hospice care from (12/11/22 through 07/10/23) and that hospice is responsible for contacting the authorized representative. (S1) indicated that on 07/10/23 when (R1) was transported by Emergency Medical Services (EMS) to the hospital, the hospice nurse was attending to (R1) on that day. A hospice nurse contacted an authorized representative about the nature of (R1)'s condition, rather than a member of the facility staff.

On 04/04/24 between 10:00 am to 10:30 am, the Department interviewed hospice administrator witness #1 (W1) who verified that their nurse was on duty on 07/10/23 when (R1) was found unresponsive. It is the role and responsibility of the hospice nurse to contact the authorized representative and not the facility staff. (W1) explained (R1)’s power of attorney was (W2) and had some ongoing health issues and was not available. (W1) claimed that when (W2) was not available the hospice team was instructed to contact a family member (W3) who resided out of state and an agreement that was arranged with Providence Hospice, Inc. (W1) stated the hospice team evaluates (R1)’s condition and provides updates the plan of care as symptoms and condition change, even on a day-to-day basis.

On 04/04/24 between 10:30 am to 03:00 pm the Department interviewed family representative witness #3 (W3) who verified through hospice arrangement (W3) is to be contacted when (W2) is not available with (R1)’s condition. Six (6) out of six (6) witnesses #4 - #9 (W4-W9) reported although the residents are not in hospice, the facility staff provided updates and condition changes of residents to the authorized representative.
(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 11-AS-20230803103418

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 06/20/2024

NARRATIVE

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Providence Hospice, Inc. communication log (dated: 12/11/22 – 07/19/23) verified that the hospice nurse contacted (W2) with (R1)’s change in condition and requested to call 911 for further evaluation. The hospice medical doctor and care team were informed and adapted to the family member's decision.

A review of Unusual Incident Report LIC 624 (dated: 07/10/23) the hospice nurse was at the facility who notified the facility staff to contact 911, and the nurse informed the family representative to have (R1) sent to the hospital. Based on the information gathered, the allegation mentioned above does not have sufficient evidence to support it.

Allegation #6: Staff did not notice residents change in condition.

It is alleged that facility staff did not observe (R1)’s change in condition. The complainant felt that the facility staff did not notice the resident's change in condition before the resident became unresponsive. (R1) was evaluated with Sepsis and a UTI when admitted to the hospital.

On 04/04/24 between 8:30 am to 03:30 pm, the Department interviewed (A1) and staff# 1 -#3 (S1-S3) all refuted this allegation. (R1)'s medical needs were always taken care of by hospice medical professionals, according to (A1 and S1). (A1-S1) argued that the facility's staff were responsible only for (R1)'s non-medical care since the facility was a non-medical care facility. (A1 and S1-S3) all said that although they are not medical professionals, they are qualified to supervise and care for residents. (S1-S3) stated Daily Body Checks, Two-Hour Incontinent Check, and One-Hour Monitoring Check are performed in all shifts. (S1-S3) reported that the facility maintains Caregiver Notes and Personal Care Logs as a means of communicating with staff regarding the resident's care condition.

On 04/04/24 between 09:00 am to 02:22 pm, the Department interviewed (9) out of (9) residents #2 - #10 (R2-R10) all claimed the staff were responsive to their care needs. The staff conducts routine checks throughout the day and will call out any resident’s change in condition that may require medical assistance.
On 04/04/24 between 10:30 am to 03:00 pm, the Department interviewed family representatives (5) out of (6) witnesses #3 - #9 (W3-W9) expressed the facility staff are good at detecting and promptly reporting changes in resident's condition as it ensured the resident's well-being and safety.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 11-AS-20230803103418

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 06/20/2024

NARRATIVE

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A review of Harbor UCLA Medical Records (dated: 07/14/23) (R1’s) listed (17) active medications. Fourteen (14) out of (17) revealed potential side effects to unitary tract infection (UTI) or Sepsis according to (National Institute of Health NIH.gov). Facility Medication Administrator Record (MAR) (dated: 05/01/23 - 07/01/31/23) revealed that (R1) was on (27) active medications. Twenty-four (24) out of twenty-seven (27) had some association of potential side effects to (UTI) or Sepsis.

A review of Providence Hospice, Inc. Communication Log (dated: 12/11/22 – 07//19/23) documented that the facility staff and hospice nurse were involved in (R1)’s change in condition. It was noted that facility staff alerted the hospice nurse of (R1)’s condition with no response starting in the morning of 07/10/23 per the staff report. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above.

The Department was not able to interview resident #1 (R1), due to her passing away on 07/25/223, so an interview was not possible.

Based on the evidence gathered and interviews conducted, and analysis of records reviewed, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations of NEGLECT/LACK OF SUPERVISION in this complaint are found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to the Administrator (Ginger Enriquez).

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024

LIC9099 (FAS) - (06/04)

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