198601976-10-14-2022-28-AS-RORN-CKBUNB-20221018154340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601976
Report Date: 08/25/2022
Date Signed: 10/14/2022 01:23:34 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
08/22/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220822151425

FACILITY NAME:	DEL MAR PARK		FACILITY NUMBER:	198601976
ADMINISTRATOR:	DENISE SUTTON		FACILITY TYPE:	740
ADDRESS:	990 EAST DEL MAR BOULEVARD		TELEPHONE:	(626) 577-0215
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	60	CENSUS: 49	DATE:	08/25/2022
		UNANNOUNCED	TIME BEGAN:	12:17 PM
MET WITH:	Dana Perez - Resident Services Coordinator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility staff not providing a safe environment to the residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Dana Perez Resident Service Coordinator an explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested a copy of staff and resident roster. LPA conducted a tour of the facility's common areas, and isolation area(s). LPA Flores interviewed staff #1(S1),#2(S2),#3(S3),#4(S4), resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),attempted to interview staff #6 over the phone, and interviewed staff #5(S5) over the phone. LPA reviewed facility's infection control plan, test results for staff, and requested copies of staff's PCR test results for 8/11/22, 8/15/22, 8/19/22 and staff schedule for the month of August.

The investigation revealed the following: Regarding allegation: Facility staff not providing a safe environment to the residents. It is alleged facility's staff #5 was sick on 8/16/22, staff #5 was "careless" continuing to pull mask down when speaking to residents and staff and continued to work. (CONTINUED LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

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-20220822151425

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: DEL MAR PARK	FACILITY NUMBER: 198601976
	VISIT DATE: 08/25/2022

NARRATIVE

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Interviews with residents revealed 3 out of 5 residents interviewed stated staff pull their face mask down when speaking to residents in care and 1 out of the 3 stated only the administrator pulls the face mask down when speaking to the residents. 2 out of 5 residents stated staff do not pull their face mask down when speaking to the residents. 5 out of 5 residents interviewed stated facility is following COVID 19/Infection control protocols and staff do not provide care while experiencing symptoms. Interviews with staff revealed 3 out of 5 staff stated to pull their face mask down when speaking to the residents and maintaining social distancing when pulling the face mask down, 1 out of the 3 specified to pull face mask down to speak to a resident that can only communicate by lip reading. 3 out of 5 staff stated staff/administrator has not been observed working while experiencing symptoms. 2 out of 5 staff stated to have observed staff working while experiencing symptoms. 4 out of 5 staff stated facility is providing them with training and updates regarding COVID 19 or Infection control protocols. Interview with Administrator determined S5 showed symptom of a cough on 8/17/22 and conducted an antigent/rapid test on 8/17/22 which was not determined whether it was positive or negative. S5 conducted a PCR test on 8/18/22 and received test results on 8/19/22 around noon, continued to work until 4:30pm and began isolation at home after 4:30pm. LPA Flores reviewed Primelab test results for S5 collected on 8/11/22 and 8/15/22 with results: not detected and 8/18/22 results: detected.

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.

Exit interview was conducted with Dana Perez - Resident Service Coordinator and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220822151425

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: DEL MAR PARK	FACILITY NUMBER: 198601976
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/26/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(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 will ensure that all staff/administrator are practicing safety guidelines and will schedule infection control, CDC recommendations, department of public health guidelines and CCLD PINs in - service training for all staff by POC due date 8/26/22. Licensing will submit a copy of all in-services agendas and sign-in logs by 9/8/22.
	8 9 10 11 12 13 14	Based on interviews and document review conducted licensee did not ensure that all staff are practicing safety precautions by keeping face mask while providing care and staying home when symptomatic which poses a personal rights, health, or safety risk to the residents in care.	8 9 10 11 12 13 14
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	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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

LIC9099 (FAS) - (06/04)

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