198601953-5-12-2022-28-AS-WSHO-CF92PW-20220609173501

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601953
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:37:33 PM

Unsubstantiated

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
05/02/2022 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220502163815

FACILITY NAME:	KENSINGTON SIERRA MADRE, THE		FACILITY NUMBER:	198601953
ADMINISTRATOR:	CECILIA DEGRAFF		FACILITY TYPE:	740
ADDRESS:	245 W. SIERRA MADRE BLVD.		TELEPHONE:	(626) 355-5700
CITY:	SIERRA MADRE	STATE: CA	ZIP CODE:	91024
CAPACITY:	106	CENSUS: 86	DATE:	05/12/2022
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	C.C. Degraff, Administrator		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Facility staff dropped resident resulting in injury.
Resident has a pressure injury while in care.
Resident had torn/ripped and stretched out clothing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegations listed above. LPA met with Administrator, C.C. Degraff and explained the reason for the visit.

The investigation consisted of the following: Interviews were conducted with 7 staff, Resident #1 (R1), and R1's family. R1's file was also reviewed which included physician's report, needs and services plan, emergency contacts, and incident reports. The facility was also toured.

The investigation revealed the following: On 4/30/22, R1 had a fall at the facility. It's alleged R1 was dropped by facility staff. Staff interviewed reported R1 was placed in bed a little before 7:00 pm. At 7:00 pm the night staff started their shift and checked on R1. R1 was seen on the floor next to the bed. A Medication Technician (Med Tech) assessed R1 and decided to call 911. Paramedics arrived and transported R1 to the hospital. R1 returned to the facility the next morning. R1 did not sustain any major injuries.
Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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-20220502163815

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: KENSINGTON SIERRA MADRE, THE	FACILITY NUMBER: 198601953
	VISIT DATE: 05/12/2022

NARRATIVE

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R1 resides in the memory care unit and is diagnosed with dementia. R1 could not remember the details of the fall. There were no other witnesses to the fall. Based on the information obtained, the allegation is unsubstantiated.

It's also alleged R1 has a pressure injury on the knee. Staff interviewed indicated R1 sustained a small scrap on the right knee from the fall. It would not be diagnosed as a pressure injury. Discharge documents from Methodist Hospital indicates a CT brain scan was performed. There was no evidence of head trauma or any other injuries from the fall. There was no mention of a knee injury. R1 was interviewed and could not report what injuries were sustained from the fall if any. Based on the information obtained, the allegation is unsubstantiated.

The last allegation states R1 had torn, ripped or stretched out clothing when the fall occurred. Staff interviewed indicated R1 does have some older shirts that he/she will wear at bed time. Staff interviewed denied R1 was pulled from his/her clothing while being assisted after the fall. R1 could not report what occurred during the fall due to a dementia diagnosis. R1's family did not have any concerns regarding the care being provided at the facility. Based on the information obtained, the allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview held. A copy of the report was provided to Administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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