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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602255
Report Date: 09/16/2023
Date Signed: 09/16/2023 12:23:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
11/17/2021 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211117143322
FACILITY NAME:CALIFORNIA MENTOR - DOMINGUEZ HOMEFACILITY NUMBER:
198602255
ADMINISTRATOR:SIGNEY, RACHELFACILITY TYPE:
735
ADDRESS:214 E DOMINGUEZTELEPHONE:
(909) 483-2505
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:3CENSUS: 3DATE:
09/16/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Glendy FrancoTIME COMPLETED:
10:01 AM
ALLEGATION(S):
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Resident sustained a severe infection while in care.
Staff do not assist resident with incontinence care.

INVESTIGATION FINDINGS:
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On 09/16/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit at this facility, LPA was greeted by Direct Support Professional Glendy Franco . Franco contacted Claudio Rosas Executive Program Director by telephone and the purpose of the visit was explained. Rosas who could not be at the facility was provided the information by phone.

The investigation consisted of the following: Investigation visit on 11/18/21, 01/14/22, 04/11/22 and 09/16/23. Interviews with staff #1-#3 (S1-S3) and clients #1-#2 (C1-C2), and witnesses #1-#5 (W1-W5). Record reviews for (C1’s) Pre-Appraisal Report, ISP Quarterly Nursing Assessment, Comprehensive Nursing Assessment, Nursing Progress Notes, Incident Reports, Harbor UCLA Medical Records, Torrance Memorial Hospital Medical Records, Medication Administration Record; Centrally Stored medication and Destruction Record, Medication Refill Log, Medication & PRN List. and other pertinent documents associated with this complaint. A tour of the entire facility was conducted.
(Evaluation Report Continues on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023
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-20211117143322
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - DOMINGUEZ HOME
FACILITY NUMBER: 198602255
VISIT DATE: 09/16/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Resident sustained a severe infection while in care.
Allegation #2: Staff do not assist resident with incontinence care.

The details for the complaint alleged client #1 (C1) sustained a severe infection while in care by staff at this facility. It was reported on 11/03/21, (C1) was taken to Harbor UCLA Medical Center Hospital due to a severe rash on the posterior. On 11/12/21, (C1) was later transferred to Torrance Memorial Hospital for MRSA and E. coli infection. The complainant reported (C1) is left in diapers for prolonged periods at night and during the day.

Harbor UCLA Medical records (dated 04/14/22) revealed (C1) was assessed with raw, skin peeling/slothing off and no active bleeding/drainage in the buttocks. On 11/04/21 hospital’s wound care consultants completed a complete skin assessment with (C1) noted to have Incontinence Associated Dermatitis (IAD) extending to the bilateral buttock and exposed dermis. On 11/05/21 (C1’s) history and physical indicated skin superficial skin loss/breakdown along posteromedial and scrotal area. Finding favored to represent cellulitis. On 11/05/21, (C1’s) history and physical findings are favored to represent cellulitis. Blood culture growth revealed Methicillin resistant Staphylococcus Aureus (MRSA).

On 03/24/22, 03/25/22, and 04/13/22, the Department interviewed by phone (4) medical professionals and (1) service coordinator. (3) out of the (5) witnesses #1-#3 (W1-W3) confirmed that(C1) was being treated for cellulitis or some type of bacterial infection.

On 04/13/23 between 3:00 pm – 4:00 pm, the Department interviewed by phone (3) facility staff. (3) out of (3) staff #1-#3 confirmed (C1) wore adult pull-up diapers and was unable to wipe oneself. (S1-S3) acknowledged that (C1) had some types of rash and routine body checks were conducted. (S1-S3) reported (C1) was changed every (2) hours or as needed.

On 04/13/22, between 3:00pm – 4:00pm, the Department reviewed client #1-#2 (C1-C2) service records and attempted to interview (C1-C2) by phone and were unable to hold a conversation as a result of their disability.

(Evaluation Report Continues on LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20211117143322
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CALIFORNIA MENTOR - DOMINGUEZ HOME
FACILITY NUMBER: 198602255
VISIT DATE: 09/16/2023
NARRATIVE
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Investigation revealed the staff and registered nurse were aware (C1) had a previous history of Cellulitis and was treated for it on 01/08/20. The facility failed to properly assess and develop a plan of care (skin breakdown prevention and incontinent care) for the resident to meet (C1’s) needs. The facility failed to regularly check (C1’s) skin for signs of injury and monitor (C1’s) skin resulting in infection MRSA which placed (C1) in additional discomfort and hospitalization. The facility failed to provide proper care and supervision as evidenced by (C1’s) acquired MRSA infection and erosive dermatitis while in resident care at the facility, a sign that the resident was not provided the needed frequency for changing diapers and/or proper peri-care. The facility failed to follow the doctor’s orders to apply double antibiotic ointment to open wounds/scratches, (2) times as needed for lesions or scratches to buttocks, every diaper change as required for the rash on 10/28/21, 11/02/21, and 11/03/21. The facility failed to document and address (C1’s) wound was identified by staff on 11/02/21. The facility failed to monitor (C1’s) bladder and bowel movement, which contributed to (C1’s) skin problems.

Based on the information gathered, there is sufficient evidence of neglect/lack of care to corroborate the allegations mentioned above.

Based on observations, interviews, and record reviews, 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 9099-D.

An exit interview was conducted with Glendy Franco, Direct Support Professional, and a hard copy of the report along with appeal rights.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20211117143322
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CALIFORNIA MENTOR - DOMINGUEZ HOME
FACILITY NUMBER: 198602255
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2023
Section Cited
CCR
85075.4
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85075.4 Observation of the Client - (a) The licensee shall regularly observe each client for changes in physical, mental, emotional, and social functioning. (b)The licensee shall provide assistance... require a change in the existing level of service... . (c) The licensee shall bring observed changes...
This requirement is not met as evidenced by:
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Licensee/Administrator will adhere to Title 22 Sec.85075.4 and agreed to conduct an in-service training to ensure that staff document changes in clients' physical and mental health by POC due date: 09/17/23.
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Based on observations, record reviews, and interviews, the licensee did not comply with this section. The facility failed properly assess and develop a plan of care (skin breakdown prevention and incontinent care) condition. This violation which poses an immediate health, safety, or personal rights risk to persons in care.
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Type B
09/30/2023
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights - (a) Each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment to meet his/her needs.
This requirement is not met as evidenced by:
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Licensee/Administrator will ensure that the facility staff is trained and comply with Title 22 Regulations Sec.80072. The facility will conduct a training for all staff regarding client’s personal rights and provide proof of training with all staff signatures by POC due date: 09/30/23.
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Based on observations, record reviews, and interviews, the licensee did not comply with this section. The facility failed a safe and healthful enviroment by providingproper care and supervision as evidenced by (C1’s) acquired MRSA infection. This violation which poses an immediate health, safety, or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4