198602134-6-4-2021-28-AS-MVAO-C4PSEP-20210707134904

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602134
Report Date: 06/04/2021
Date Signed: 06/04/2021 01:42:09 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,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2020 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200213153920

FACILITY NAME:	GLEN PARK AT LONG BEACH		FACILITY NUMBER:	198602134
ADMINISTRATOR:	PINK, MARINA E		FACILITY TYPE:	740
ADDRESS:	1046 E 4TH ST		TELEPHONE:	(562) 432-7468
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY:	208	CENSUS: 71	DATE:	06/04/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Melissa Flores (Administrator)		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Lack of care resulted in resident falls and resident sustaining multiple fractures.
Staff did not obtain medical care for resident in a timely manner.
Staff did not follow up on obtaining doctor’s orders for resident medication which led to fall.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted a site visit to delivered complaint findings for the allegations listed above. Upon arrival, LPA met with Melissa Flores. and explained the purpose of the visit.

During the initial complaint investigation conducted on 02/14/20, LPA made an unannounced site visit to the facility and obtained a copy of the Staff/Resident roster and conducted a health and safety check. LPA toured the facility with Ghea Guzman and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. There are no immediate health and safety concerns during visit on 02/14/20.

Regarding the allegation: Lack of care resulted in resident falls and resident sustaining multiple fractures.

The Department’s investigation consisted of interviews with resident #1 And staff #1 - #17. Review of resident #1 facility file and medical reports. Continue to LIC9099C....

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

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 6

Control Number 28-AS-20200213153920

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT LONG BEACH	FACILITY NUMBER: 198602134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 06/05/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Facility neglected to develop a care plan to assist R#1 with adequate supervision due to wandering and being	1 2 3 4 5 6 7	Licensee shall send a letter to licensing indicating the licensee has read and comply with section 87411(a) by POC due date.
	8 9 10 11 12 13 14	a fall risk, which resulted in R#1 falling three times in the facility in June 2019 and sustained a fracture of the left clavicle and right femoral neck (Right Hip).	8 9 10 11 12 13 14	*An immediate Civil Penalty was issued in the amount of $500 for lack of care, which resulted in R#1 receiving medical treatment due to sustaining an injury. Deficiency was cited on LIC809D.*
Request Denied Type A 06/05/2021 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care (a) (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by: The facility did not seek medical treatment immediately after the 06/22/19 incident and waited for several days to have R#1 evaluated by a medical professional, R#1 was seen	1 2 3 4 5 6 7	Licensee shall conduct staff training to ensure residents are being provided with medical assistance as necessary and provide proof of training along with a letter to licensing indicating the licensee has read and comply with section 87465(a)(2) by 06/11/21.
	8 9 10 11 12 13 14	by a medical professional on 06/26/19 for an unrelated condition and seen on 06/27/19 after falling again in the facility. R#1 X Ray’s dated 06/26/19 and 06/27/19 revealed R#1 sustained a fractured left clavicle and a fracture right hip.	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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 28-AS-20200213153920

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT LONG BEACH	FACILITY NUMBER: 198602134
	VISIT DATE: 06/04/2021

NARRATIVE

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The investigation revealed that R#1 had a history of falls prior to being admitted to the facility on 03/20/17. R#1 was assessed by the facility on several occasion and determined was diagnosed with dementia, was a fall risk and in need of additional supervision due to wandering and being a fall risk as supported by the following documents; 03/20/17 - Functional Capability Assessment, Preplacement Appraisal, R#1 Head to Toe Assessment. R#1 Appraisal/Needs and Services Plan dated 04/27/17 indicated that R#1 has a history of falls and previous injury while residing at different facility, R#1 Assessment Tool dated 11/07/07 indicated R#1 required supervision when Resident #1 moved about the facility and was deemed to be “non-ambulatory. R#1 Physician’s Report dated 03/22/18 indicated R#1 was deemed to be “confused” and “disoriented,” and engaged in “wandering behavior.” R#1’s Individual Service Plan’s (ISP) dated 05/8/18, 11/27/18, 07/30/18 indicated R#1 is at risk for falls and potential for injury due to difficult walking, muscle weakness. At risk for musculoskeletal deconditioning, muscle atrophy and generalized weakness r/t patient’s decreased functional mobility and 02/14/19 - Appraisal/Needs and Services Plan documented that R#1’s doctor ordered a wheelchair, but R#1 refused it.

The investigation revealed R#1 fell or was found on the floor after a fall while residing in the facility on three separate occasions in the month of June 2019 as evidenced by incidents that occurred on 06/05/19, 06/22/19 and 06/27/19. Per the 06/27/19 incident, R#1 was observe by staff #1 falling while watching the surveillance monitor and went to assist R#1 and 911 was called. Paramedics took R#1 to the hospital for treatment due to R#1 being in pain after the fall. Per the hospital records dated 06/27/20, R#1 was seen for the 06/27/19 fall and X Ray revealed R#1 sustained fractures of the left clavicle and a right hip fracture. On 06/22/21, R#1 fell in the facility, however, R#1 was not taken to the hospital for evaluation as R#1 did not have any signs or symptoms of pain and denied pain for the 06/22/19 incident report. Therefore, the facility was aware that R#1 has fallen in the facility three time in less than a thirty day period and had ample notice that R#1 required more care and supervision and develop a care plan of care to assist R#1 with her needs for assistance with wandering, falls while ambulating, however the facility neglected to develop a care plan to assist R#1 with adequate supervision due to wandering and being a fall risk, which resulted in R#1 falling three times in the facility in June 2019 and sustained a fracture of the left clavicle and right femoral neck (Right Hip).

Continue to LIC9099C....

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 28-AS-20200213153920

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT LONG BEACH	FACILITY NUMBER: 198602134
	VISIT DATE: 06/04/2021

NARRATIVE

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In regards to the allegation: Staff did not obtain medical care for resident in a timely manner.

On 06/22/19, during an evening room check, staff#1 found R#1 on the floor of resident room, however, R#1 was not evaluated by a medical professional for injury, because it was unclear whether R#1 had fallen, despite the facility policy that an unwitnessed fall of a resident with dementia would always result in medical evaluation. During the 06/22/21 assessment of R#1, staff #1 assessed R#1 extremities for range of motion and observed no indication of R#1 experiencing pain. However, Staff #2 informed the Department that R#1 did in fact verbalize pain during the 06/22/19 assessment. When Resident #1 was seen at the hospital on 06/26/19 for an unrelated evaluation, R#1 complained of extreme pain to the upper left arm and dark bruising was observed. R#1 facility records nor staff member statements noted R#1 to be in any pain between 06/22/2019 and 06/26/2019, but R#1 bruising on the left arm and shoulder would have been readily apparent when caregivers assisted R#1 with getting dressed and other activities of daily living and R#1 was to receive stand-by assistance when ambulating. On 06/27/19, R#1 was examined at the hospital due to a fall in the facility that morning and R#1 X-Rays revealed R#1 left clavicle fracture and X Rays taken at a different hospital on 06/26/2019 also showed R#1 to have a fractured left clavicle. Therefore, had the facility arranged for R#1 to be medically evaluated after R#1 was found on the floor on 06/22/2019 or when the bruising to R#1’s arm first became apparent, R#1 could have been provided with medical treatment for R#1 injury at an earlier time. The investigation revealed, on 06/22/19, staff #1 found R#1 on the floor of resident room and the facility failed to obtain timely medical treatment. The facility did not seek medical treatment immediately after the 06/22/19 incident and waited for several days to have R#1 evaluated by a medical professional, R#1 was seen by a medical professional on 06/26/19 for an unrelated condition and seen on 06/27/19 after falling again in the facility. R#1 X Ray’s dated 06/26/19 and 06/27/19 revealed R#1 sustained a fractured left clavicle and a fracture right hip.

Continue to LIC9099C....

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 28-AS-20200213153920

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT LONG BEACH	FACILITY NUMBER: 198602134
	VISIT DATE: 06/04/2021

NARRATIVE

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In regards to the allegation: Staff did not follow up on obtaining doctor’s orders for resident medication which led to fall.

The Department’s investigation consisted of interviews with resident #1 And staff #1 - #17. Review of resident #1 facility file and medical reports. The investigation revealed that R#1 had a history of falls prior to being admitted to the facility on 03/20/17. R#1 Functional Capabilities Assessment upon being admitted to the facility indicated R#1 was able to walk and transfer from bed with out assistance and would require grab bars and assistance with activities of daily living (ADLs). R#1 medication charted for May 2019 indicated R#1 was prescribed a medication on 02/19/19. Staff assisted with dispensing medication until 05/14/19 when it was discontinued by a physician. On 05/10/19 the facility received a faxed written prescription for a 30-Day supply of “Prednisone”. On 05/14/19, the facility received handwritten note indicating the medication was discharged. R#1’s June MARs listed Prednisone amongst R#1 medications. On 06/27/19, R#1 was given a new written order for a 90-Day supply of “Prednisone” which was filled by the pharmacy on 06/27/19. During the Month of June 2019, R#1 had three separate incidents, (06/05/19, 06/22/19 and 06/27/19) where R#1 was found on the floor or fell in the facility. Therefore, the facility failed to follow up with R#1 physician regarding residents falls and securing the R#1 medication Prednisone, which R#1 relied on to relieve muscle pain and stiffness. R#1 medical records indicated that R#1 medication Prednisone was discontinued and R#1 had greater difficulty ambulating. Had R#1 received the physical therapy that doctor ordered, received stand-by assistance while ambulating, been reminded by staff to use a walker and been afforded anti-inflammatory medication, R#1 would not have experienced such frequent falls.

An immediate Civil Penalty was issued in the amount of $500 for lack of care, which resulted in R#1 receiving medical treatment due to sustaining an injury. Deficiency was cited on LIC809D.

"The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e) or (f), or 1548 (e) or (f) , 1568.0822(e) or (f)."

Based on the department's observations, interviews and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted and copy of this report and appeal rights provided to Melissa Flores.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 28-AS-20200213153920

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GLEN PARK AT LONG BEACH	FACILITY NUMBER: 198602134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 06/11/2021 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. This requirement is not met as evidenced by: The facility failed to follow up with R#1	1 2 3 4 5 6 7	Licensee shall conduct staff training to ensure staff are regularly observing changes in residents condition and meeting their needs. Licensee to provide proof of training along with a letter to licensing indicating the licensee has read and comply with section 87466 by 06/11/21.
	8 9 10 11 12 13 14	physician regarding residents falls and securing R#1's medication Prednisone, which R#1 relied on to relieve muscle pain and stiffness. R#1 medical records indicated that R#1 medication Prednisone was discontinued and R#1 had greater difficulty ambulating.	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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 6