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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601748
Report Date: 08/17/2022
Date Signed: 08/21/2022 09:59:16 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
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2022 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20220725083145
FACILITY NAME:DIAMOND STAR ASSISTED LIVINGFACILITY NUMBER:
198601748
ADMINISTRATOR:MARIA TERESA MATIASFACILITY TYPE:
740
ADDRESS:2038 W. 233RD STREETTELEPHONE:
(424) 328-0468
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 6DATE:
08/17/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:NORMA GRANETATIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident sustained skin damage while in care.
Resident is in bed for an extended period of time.
INVESTIGATION FINDINGS:
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On 8/17/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent complaint visit at this facility. LPA called the facility to conduct a risk assessment. LPA spoke with Administrator Maria Matias who confirmed the facility is Covid-19 free. LPA met with House Manager (HM) Norma Graneta shortly after and explained the purpose of today's visit.

The investigation consisted of the following: LPA Montoya conducted complaint investigations on 7/26/2022 and 8/11/2022. On 7/26/2022, LPA toured the inside and outside grounds of the facility. LPA reviewed six (6) residents’ service records, requested and obtained three (3) out of six reviewed records, staff roster and resident roster. LPA did not conduct interviews on this visit. On 8/11/2022, LPA interviewed three staff, two residents, and two witnesses. LPA delivered findings for two (2) out of four (4) allegations.

During today's visit, LPA Montoya interviewed Resident #6. LPA unsuccessfully attempted to interview a potential witness (R1's Home Health Nurse). LPA requested additional service records of R#1.

Investigation report continued in LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
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-20220725083145
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
MONTEREY PARK, CA 91754
FACILITY NAME: DIAMOND STAR ASSISTED LIVING
FACILITY NUMBER: 198601748
VISIT DATE: 08/17/2022
NARRATIVE
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INVESTIGATIONS REVEALED:

Based on the department's record reviews, R1 was admitted to the facility of 9/23/21. R1's Pre-appraisal and Physician's Report do not show any presence of pressure wounds/injuries on admission. On 9/25/21, R1 began to receive home health services from Providence Home Health (HH) Torrance. As of 7/18/2022, HH record shows R1 had a Stage 3 pressure injury on the sacral region. HH records emphasized importance of turning and repositioning. Based on the department's investigations, there was no record of body check during R1's admission. R1 is not on hospice.

Allegation: Resident sustained skin damage while in care.

It is alleged that Resident sustained skin damage while in care. Based on interview with the administrator (S1), she does not remember whether or not R1 had any pressure injury upon admission. Interview with the House Manager (S2) revealed she was not on duty when R1 was admitted. S2 stated she returned to work around 9/25/22 and observed R1 had one pressure injury on the sacral region. Interviews with R1 and W2 revealed R1 sustained a pressure injury while in care at this facility. Based on observations, interviews and record reviews conducted, there is sufficient evidence to corroborate the allegation above.

Allegation: Resident is in bed for an extended period of time.

It is alleged resident is in bed for an extended period of time. Interviews with R1 and W2 revealed facility staff did not reposition R1 prior to sustaining a pressure injury on her coccyx. R1 stated that after she sustained a pressure injury, staff would reposition her only before lunch and when she calls them for assistance. R1 stated she does not call staff for help because she does not want to bother them unless they come to her bedroom to reposition her. Based on the department's observations, interviews and record reviews, R1 sustained a pressure injury after her admission to the facility which indicates a neglect/lack of supervision which caused R1 to sustain a Stage 3 pressure injury.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met: Due to neglect/lack of supervision, "Resident sustained skin damage while in care" and "Resident is in bed for an extended period of time" therefore the above allegations “ are found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citations issued (ref. LIC 9099D) and civil penalty assessed.

Due to technical difficulties, LPA was not able to provide a hard copy of the report to the facility.

An exit interview was conducted with House Manager, Norma Graneta. and a copy of the Complaint Report and Appeal Rights were emailed to Licensee/Administrator Maria Teresa Matias.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220725083145
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
MONTEREY PARK, CA 91754

FACILITY NAME: DIAMOND STAR ASSISTED LIVING
FACILITY NUMBER: 198601748
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2022
Section Cited
CCR
87615(a)(1)
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87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by:
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Administrator will review Title 22 Regulations, Section 87615 (a)(1) and submit a detailed written plan on how the facility will handle residents with prohibited health conditions while in care. Because the Administrator retained Resident #1 at the facility with prohibited pressure injuries (Stage 3) without hospice care, civil penalties are assessed in the amount of Five-hundred Dollars ($500). This plan is due to the CCLD/El Segundo ASC Office by POC date.
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Based on the evidence provided, Resident #1 is in bed for an extended period of time and sustained a Stage 3 pressure injury on the sacral regiion while in care. This poses an immediate risk to health, safety and/or personal rights to residents in care.
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CIVIL PENALTY ASSESSED
Type A
08/18/2022
Section Cited
CCR
87405(a)(d)(1)(2)
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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules, and regulations.
This requirement was not met as evidenced by:
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Administrator will read Title 22, Section 87405(d)(1) “Administrator – Qualifications and Duties” The Administrator shall review regulations that specifically address certain issues; such as, the admittance and/or retention of a resident with a prohibited health condition. The administrator shall display knowledge of the requirements for providing care and supervision. A self-certification statement shall be shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov
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Based on information gathered, interviews, and records review, the administrator failed to display knowledge of the requirements for providing care and supervision appropriate to the residents and knowledge of and ability to conform to the applicable laws, rules, and regulations by retaining a resident with a prohibited health condition. This poses an immediate risk to health, safety and/or personal rights to residents in care.
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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 AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3