198601838-9-7-2023-28-AS-LHIS-CWHJQW-20231011071546

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601838
Report Date: 09/07/2023
Date Signed: 09/07/2023 09:50:51 AM

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
03/29/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210329085008

FACILITY NAME:	DOWNEY RETIREMENT CENTER		FACILITY NUMBER:	198601838
ADMINISTRATOR:	MARY MIMS-BURRIS		FACILITY TYPE:	740
ADDRESS:	11500 DOLAN AVENUE		TELEPHONE:	(562) 869-2416
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY:	252	CENSUS: 131	DATE:	09/07/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Brandie Mendibles, Administrator		TIME COMPLETED:	09:55 AM

ALLEGATION(S):

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Resident sustained visible abrasion, bruises and wounds while in care.
Resident was found laying in feces.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent visit to deliver findings on the investigation conducted by DSS Investigation Branch Investigator Laura Garcia. LPA met with Administrator Brandie Mendibles and explained the purpose of the visit.

The investigation consisted of the following: On 3/30/21, LPA Cynthia Chan initiated a telephonic visit with former Administrator Michele Goodney due to COVID-19 pandemic. A Facetime virtual tour of common areas and rooms #101, #106, #148, #224, #239, #246, and #275 was conducted. Resident (R1's) file documents were requested. Administrator emailed the following documents: Emergency and Identification form, current Physician's Report, Appraisal/Needs and Services Plan, Medication logs from January 2021 through Present, and recent hospital admission/discharge paperwork.

***Narrative summary continues next page.

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: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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-20210329085008

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: DOWNEY RETIREMENT CENTER	FACILITY NUMBER: 198601838
	VISIT DATE: 09/07/2023

NARRATIVE

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Allegation: Resident sustained visible abrasion, bruises, and wounds while in care. It is alleged that facility caregivers neglected resident (R1's) care because abrasions, bruises, and wounds evaluated by medical personnel indicated the injuries were not recent and had been there a while. Based on DSS Investigator Laura Garcia's investigation, the findings indicate that facility caregivers staff (S1) and (S2) neglected to provide adequate care for resident (R1) because they were not aware of the severity of resident (R1's) injuries. According to caregiver staff, the resident displayed signs of early Dementia and had aggressive behaviors, which made it difficult for caregivers to provide incontinence care and assist Activities of Daily Living (ADL's) i.e. showers and dressing. Per staff interviews, the facility had staffing shortages at that time. Therefore, staff failed to meet the needs of resident (R1) and did not provide proper care and supervision. Furthermore, facility staff did not provide investigator notes and/or logs pertaining to resident (R1's) care, and were not able to give details of the plan of care, or R1's prior condition to injuries sustained. The resident was enrolled in home health or hospice care prior to this incident. On March 27, 2021, R1 was transported to hospital Emergency Room. Medical records indicate that the resident’s bruising was due to prolonged immobility, which reflects a lack of care and supervision as the facility knew R1 needed assistance with repositioning and transferring. The resident also suffered from sepsis, acute Urinary Tract Infection (UTI), acute cellulitis, and skin excoriations to back, RUE, right axilla, buttocks, multiple erythematous lesions to bilateral knees and shins. Based on records and photographs, there is enough evidence to corroborate the allegation.

Allegation: Resident was found laying in feces. It is alleged that facility caregivers failed to provide incontinence care to resident (R1) because on March 27, 2021 at approximately 4:35 PM, resident (R1) was found on the bathroom floor naked, awake, with feces residue on waist, legs, and ankles covering the right side of the body. The resident was not able to get up on it's own. A body check assessment by law enforcement found the resident had feces residue on right palm, index finger, and thumb indicating the resident had not been bathe properly and/or cleaned after using the restroom. Per record review, the last appraisal (3/30/2021) indicated R1 had an increase in cognitive impairment related to short term memory with episodes of forgetfulness. Staff acknowledged that R1 had been recently transferred to the facility first floor due to requiring higher level of care. In addition, staff stated that they were not performing body checks on the resident, and would only knock on the door and make sure the resident was fine. Photograph evidence and interviews conducted supports the allegation.
*****Administrator was informed that an enhanced civil penalty might be assessed based on H & S Code.
Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per Title 22, deficiencies are cited.

Exit interview was conducted with Brandie Mendibles. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210329085008

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: DOWNEY RETIREMENT CENTER	FACILITY NUMBER: 198601838
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/08/2023 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 agress to: 1. Conduct staff training on regulation 87466 and staff communication protocols regarding changes in residents conditions. 2. Submit a written plan by tomorrow how the deficiency will be corrected. 3. Submit proof that staff were trained by 9/14/2023.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Based on medical record review and interviews, staff failed to provide provide adequate care and supervision, which resulted in injuries to R1 that required hospitalization. This is an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14
Type A 09/08/2023 Section Cited CCR 87101(c)(3)(A)	1 2 3 4 5 6 7	Definitions. "Care and Supervision" means those activities which if provided shall require the facility to be licensed... "Care and Supervision" shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents:	1 2 3 4 5 6 7	Administrator agreed to submit a care plan that addresses care responsibilities/protocols for residents with declining/change in health conditions. Submit POC by tomorrow.
	8 9 10 11 12 13 14	(A) Assistance in dressing, grooming, bathing and other personal hygiene; This requirement was not met evidenced by: Per record review & photographs, caregiver staff failed to provide assistance services as indicated on Resident Appraisal dated 3/30/2021; which poses an immediate health, safety or personal rights risk to persons 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC9099 (FAS) - (06/04)

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