198601660-5-5-2023-28-AS-RORN-CRRV7M-20230512161122

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601660
Report Date: 05/05/2023
Date Signed: 05/05/2023 02:50:40 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 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
05/12/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210512084425

FACILITY NAME:	POSADA AT WHITTIER		FACILITY NUMBER:	198601660
ADMINISTRATOR:	JANETTE HILL		FACILITY TYPE:	740
ADDRESS:	8120 S PAINTER AVE		TELEPHONE:	(562) 945-2651
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90602
CAPACITY:	0	CENSUS: 85	DATE:	05/05/2023
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Diana Bautista, Administrator		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Neglect/Lack of Supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegation. The purpose of the visit was discussed with current licensee " La Posada" Administrator Diana Bautista.

The investigation consisted of the following: On 5/19/2021 at 3:49 PM, a health and safety check and physical plant tour of resident rooms [203, 206, 215, 220, 222, 228, 301, 304, 314, 320] was conducted. Resident (R1) died on May 16, 2021 and was not interviewed. A total of four (4) staff and resident (R1's) family were interviewed. Resident (R1's) file documents were obtained.

See next page for report continuation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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 28-AS-20210512084425

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: POSADA AT WHITTIER	FACILITY NUMBER: 198601660
	VISIT DATE: 05/05/2023

NARRATIVE

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Allegation: "Neglect/Lack of Supervision." It is alleged that on 5/8/2021, medical emergency personnel entered resident (R1's) room and observed unsanitary conditions due to neglect of care. The room was extremely messy and feces were observed all over the bathroom and on the resident. Based on file review and interviews conducted, resident (R1) was able to perform it's own Activities of Daily Living (ADLs) and most of the time did not allow staff to enter the resident's room. As a result, facility staff did not regularly check-in on the resident as required. In April 2021, there were 4 unusual incidents involving resident (R1). Per staff interviews, R1 often blocked staff from entering it's room and always refused assistance. The resident never came out of the room and had all meals delivered to the room. R1 only allowed two specific staff into the room; a housekeeper and maintenance staff.

On 5/8/2021, resident (R1) refused breakfast and lunch. During dinner time staff knocked on R1's door and there was no response. Staff found the resident shirtless with feces on it's body and in the bathroom. A change in condition had been noted since at least 4/24/2021. The resident had a total of four (4) unusual incidents in April 2021 indicating there was a mental and/or physical change of condition. Staff stated that the incidents were not typical for R1, but staff did not perform room checks as required. Family interview confirmed resident (R1) refused staff assistance and had health and mental health conditions that required attention. The findings indicate that the resident likely self-neglected itself because it refused staff assistance and/or room checks. However, a resident's refusal of services and routine observation/assessments do not relieve the facility of care and supervision responsibilities.

Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is cited according to California Code of Regulations, Title 22. See LIC 9099D.

Exit interview was conducted with Administrator Diana Bautista ---. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20210512084425

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: POSADA AT WHITTIER	FACILITY NUMBER: 198601660
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/06/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.....the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	Administrator stated staff training was conducted in May 2021 regarding regulation 87466, and staff communication protocols regarding changes in residents conditions. Submit proof of staff training by tomorrow.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: On 5/8/2021, staff found R1 in need of medical attention; with feces on body and bathroom. R1 had documented changes in condition prior the incident and was not reassessed. R1 died on 5/16/21 at the hospital. This poses an immediate a health and safety risk to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC9099 (FAS) - (06/04)

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