198601953-4-25-2024-28-AS-RORN-D5PKZM-20240528082056

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601953
Report Date: 04/25/2024
Date Signed: 04/25/2024 04:44:45 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/12/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220112133834

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:	04/25/2024
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	CC DeGraff - Executive Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.
Staff did not seek medical assistance for resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted a subsequent complaint visit in response to the above mentioned allegations. LPA met with Executive Director CC DeGraff and explained the reason for the visit.

Investigation consisted of the following: On 01/13/22, LPA Mora requested a copy of staff and resident rosters and conducted a tour of facility and common areas. LPA observed a sufficient supply of perishable and non-perishable foods. LPA observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. On 01/13/2022, Investigation Bureau Department (IB) investigator Brian Slatic was assigned to investigate allegations "resident sustained unexplained injuries while in care" and "staff did not seek medical assistance for resident in a timely manner". The IB Investigator conducted interviews with 8 facility staff, physician/hand specialist, and requested R1’s medical records. On 04/25/24 LPA Mora conducted interviews with 3 staff, 8 residents, R1's responsible party , and delivered findings. (Continued to LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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 5

Control Number 28-AS-20220112133834

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KENSINGTON SIERRA MADRE, THE	FACILITY NUMBER: 198601953
	VISIT DATE: 04/25/2024

NARRATIVE

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The investigation revealed the following:

Regarding allegations: resident sustained unexplained injuries while in care and staff did not seek medical assistance for resident in a timely manner, it is alleged that R1 sustained fractured ribs, an injury to the wrist and a minor injury to the toe while in the care of the facility and facility did not seek medical assistance in a timely manner. On 01/04/2022 around 8am, a facility staff became aware of a possible left hand/wrist injury. S3 took a picture of the hand and send it to the Facility Medical Director via text. S3 placed an ice pack on the hand and the Facility Medical Director agreed with that treatment. On the same day around 7:09pm, S4 expressed concerns about the injury to the Facility Medical Director by email. S4 sent the Facility Medical Director the photo from the morning along with a photo recently taken for comparison. S4 inquired about getting an x-ray to rule out fracture because the injury appeared to be worsening compared to the photo taken that morning. Also, R1 was complaining of pain by that evening. However, the Facility Medical Director did not examine the hand or discuss the option of an x-ray with R1’s responsible party until the afternoon of 01/05/2022 at the facility. The Facility Medical Director told R1 that an x-ray could be done at the facility within a few hours. However, R1’s responsible party decided to take R1 to a nearby hospital emergency room but was told that the wait was going to be long and to go back to the facility and call the paramedics to be admitted quicker. R1’s responsible party attempted to do this, but the facility’s Director of Nursing Services told R1’s responsible party that they would not be calling the paramedics and explained that because the hand injury did not appear to be a medical emergency, R1 would still be triage and prioritized at the hospital. After this R1 and R1’s responsible party did not return to the facility and R1 was taken back to R1’s desert home. Eventually R1’s responsible party successfully managed to get the paramedics to take R1 to an emergency room. On 01/06/2022, R1 was diagnosed with three fractured left ribs, a contusion of his left hand and a small toe bruise. A specialist ultimately diagnosed tendon injuries to two of the fingers on his left hand. Though an unwitnessed fall was reported on the evening of 01/04/2022, no one at the facility could explain how R1 sustained these three injuries. On 06/15/2023, this case was referred to a Community Care Licensing Program Clinical Consultant and it was determined that when R1 was admitted to facility, R1 was not identified as a fall risk. However, everything points to resident being a fall risk – R1 had confusion/disorientation, anxiety, used an assistive device (walker) for ambulation, R1 advanced age (93 y/o); and R1 was on psychotropic meds. Despite not having a history of falls, R1 should have been identified as a fall risk, thereby there should have been monitoring to prevent falls/injuries.

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining unexplained injuries and facility not seeking medical assistance in a timely manner (refer to LIC 421IM).

Exit interview held and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/12/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220112133834

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:	04/25/2024
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	CC DeGraff - Executive Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not notify resident's authorized representative of an injury.
Resident's hygiene needs were not met.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20220112133834

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KENSINGTON SIERRA MADRE, THE	FACILITY NUMBER: 198601953
	VISIT DATE: 04/25/2024

NARRATIVE

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The investigation revealed the following:

Regarding allegation: staff did not notify resident's authorized representative of an injury, it is alleged that the facility never called the R1's family to report that the was injury. Interview with S1 revealed that it was S1 along with S2 that called R1's responsible party and left a voicemail. The voicemail they left just stated who they were and where they were calling from and it was regarding R1. They did not want to provide other details due to HIPAA law. R1's responsible party confirmed that the voicemail was received and did not call the facility back because the voicemail did not seem like it was something urgent. Also, R1's responsible party was planning on going the next day to visit R1. IB Investigator obtained a screenshot of the voicemail transcription which is dated 01/04/2022 with a time of 3:33pm which is the same day that R1's injury was discovered.

Regarding allegation: resident's hygiene needs were not met, it is alleged that R1 has dirty clothes and nails. Staff interviewed denied the allegation and stated that all resident's hygiene needs are being met. Residents interviewed could not corroborate the allegation and stated their hygiene needs are being met.

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 and a copy of the report was provided

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20220112133834

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KENSINGTON SIERRA MADRE, THE	FACILITY NUMBER: 198601953
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 04/26/2024 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities shall...:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee is to comply with Title 22 Section 87468.1 at all times. Additionally, Licensee will submit a statement explaining they will comply with this Title 22 regulation and submit to Community Care Licensing Division (CCLD) by 04/26/2024.
	8 9 10 11 12 13 14	Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Resident sustained unexplained injuries while in the care of this facility.	8 9 10 11 12 13 14	An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining injuries while in care. Refer to LIC 421IM.
Request Denied Type A 04/26/2024 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility...: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee is to comply with Title 22 Section 87465 at all times. Additionally, Licensee will submit a statement explaining they will comply with this Title 22 regulation and submit to Community Care Licensing Division (CCLD) by 04/26/2024.
	8 9 10 11 12 13 14	Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Facility did not seek immediate medical attention for R1 in a timely manner.	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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

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