198602069-5-21-2021-11-AS-MVAO-CFNND3-20220623102141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602069
Report Date: 04/30/2021
Date Signed: 05/21/2021 09:44:49 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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2020 and conducted by Evaluator Erik Brown

COMPLAINT CONTROL NUMBER: 11-AS-20200420103730

FACILITY NAME:	PALMCREST GRAND RESIDENCE		FACILITY NUMBER:	198602069
ADMINISTRATOR:	STREICHER, RACHEL		FACILITY TYPE:	740
ADDRESS:	3503 CEDAR AVENUE		TELEPHONE:	(562) 595-4551
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	262	CENSUS: 118	DATE:	04/30/2021
		UNANNOUNCED	TIME BEGAN:	02:21 PM
MET WITH:	Lesly Figueroa, Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility failed to meet residents medicals needs which resulted in resident death

INVESTIGATION FINDINGS:

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On this date, Licensing Program Analyst (LPA) Erik Brown conducted an unannounced complaint tele-visit to deliver findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Lesly Figueroa, the facility Administrator.

During the investigation on 4/23/20, LPA Williams conducted telephone interviews with the assistant administrator and a video call which consisted of a review of the physical plant and Resident #1’s room. LPA Williams also requested copies of R1's admission agreement, physician report, needs and services, appraisal and reappraisal, medication records, and Responsible Party information to be faxed to the LPA Williams’ attention at the Regional Office Address listed above by (323) 981-1781.
The Investigations Bureau accepted this complaint on this date 4/21/2020. According to Investigator Jose Santana, “Although the facility called 911 on 4/08/2020 for R1’s vomiting, diarrhea, and refusal to eat, the facility did not seek non-emergency transport to a hospital when the Long Beach Fire Dept. declined to

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

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 4

Control Number 11-AS-20200420103730

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: PALMCREST GRAND RESIDENCE	FACILITY NUMBER: 198602069
	VISIT DATE: 04/30/2021

NARRATIVE

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transport R1 for having insufficient symptoms. Additionally, the facility kept R1 in the same room as another resident exhibiting symptoms that Long Beach Health Dept. identified as potential COVID-19 symptoms, for which isolation was required. This other resident continued sharing a room with R1 until 4/11/2020, when the resident was transported to the hospital and was found to have pneumonia (but no COVID-19). The facility should have presumed the roommate was COVID-19 positive; its failure to isolate residents was not aligned with CCLD directives. The facility retained the resident at the facility for IV hydration treatment under care of CareMore Health. Even if an argument can be made that the facility followed appropriate COVID-19 protocol based on the Long Beach Health Dept. directives, the facility took no measures to address the many pressure injuries on R1’s body, and it retained him despite an unstageable pressure injury on his right elbow, a prohibited condition. Further, the facility not only took inadequate measures to address R1’s increased fall risk and the injuries he sustained during an unwitnessed fall that resulted in bruising to the right side of his chest, but it actually barred home health physical therapy from assessing R1, stating that this service was “non-essential” during the facility lockdown. Lastly, and perhaps most significant, the facility failed to seek adequate medical attention for R1’s caloric deficiency, weakness, and increased confusion, all of which were signs of a change of condition, which the assistant administrator and a facility License Vocational Nurse believed was sufficient reason to seek hospital evaluation. The facility was not responsive to the POA, CareMore, or the home health company during this time, creating slight delays in, and in the case of physical therapy, the barring of, the resident’s treatment. Rather than allow a physical therapist to assess R1 and prevent additional falls, facility administrator Russell Amparano informed staff members to advise R1, who was in a confused state, not to attempt to get out of bed unassisted. R1 ultimately developed an unstageable pressure injury on his right elbow, along with several stage I pressure injuries throughout the right side of his body but received no wound care. The allegation that the facility failed to seek timely medical attention for R1 is Substantiated”.

The investigation revealed the following for allegation:

(Facility failed to meet residents medicals needs which resulted in resident death)

Based on interviews conducted by Investigator Jose Santana and LPA Williams, the facility did fail to keep R1 separate from another resident who should have been isolated due to having Covid-19 symptoms. Additionally, the facility did not react appropriately to the change of condition for R1. The facility also failed to

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200420103730

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: PALMCREST GRAND RESIDENCE	FACILITY NUMBER: 198602069
	VISIT DATE: 04/30/2021

NARRATIVE

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retrieve wound care services for R1 after R1 developed multiple pressure injuries.

Based on the records that were reviewed, the interviews that were conducted, and the information obtained, although the facility called 9-1-1 on 04/08/20 to address R1’s health condition, the Administrator at the time of the incident (not Lesly Figueroa) failed to call non-emergency after the fire department declined to transport R1 for having insufficient symptoms. Based on the information, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated

Citations issued on the LIC9099-D and appeal rights given. LPA also advised the administrator that a possible ECP may be warranted.

A telephonic exit interview was conducted with Administrator Lesly Figueroa, and an electronic copy was provided via email for signature.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200420103730

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: PALMCREST GRAND RESIDENCE	FACILITY NUMBER: 198602069
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/14/2021 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465(a)(2)The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical...facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement was not met by :	1 2 3 4 5 6 7	Administrator agrees to hire a consultant to train staff and administration regarding section 87465 to ensure that residents' medical needs are met, regardless of it not being a non-medical emergency. As proof, Administrator will submit to LPA an attendance log with the training topic indicated on the log sheet.
	8 9 10 11 12 13 14	Facility failed to transfer resident to the hospital, which presented an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

LIC9099 (FAS) - (06/04)

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