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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602281
Report Date: 04/18/2022
Date Signed: 04/18/2022 09:32:29 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2019 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20190913095722
FACILITY NAME:SERENITY SENIORS HOME IIIFACILITY NUMBER:
198602281
ADMINISTRATOR:ASTIER, MAYAFACILITY TYPE:
740
ADDRESS:212 S. ESSEY AVETELEPHONE:
(424) 338-6385
CITY:COMPTONSTATE: CAZIP CODE:
90221
CAPACITY:4CENSUS: 4DATE:
04/18/2022
UNANNOUNCEDTIME BEGAN:
08:21 AM
MET WITH:Antoinette Richardson, AdministratorTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Severe neglect resulting in resident sustaining a stage 4 pressure injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit. The purpose of the visit was to correct LPA Arterberry's report dated 11/24/19. LPA Arterberry's report has been rescinded. The initial complaint visit was conducted by LPA Arterberry on 9/16/19. Investigator Santana investigated further.

The investigation consisted of the following: On 9/16/2019, LPA Arterberry reviewed and obtained copies of Resident #1’s (R1’s) file which included the following: Health screening, Medication Administration Record (MAR), Admission Agreement, Ideal Health Care (Health Screening), MAR, Restricted Health Care Plan, Purity Home Health Care Services notes, Omni Home Health Care Services notes and Nurses Notes. Investigator Santana interviewed the following individuals: R1, Licensee, Maya Astier, Administrator, Candice Fulse, Staff #1 (S1), Regional Center Quality Assurance Specialist, Purity Home Health representative and Ideal Health Care representative.

Continued on 9099C.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3969
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
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 3
Control Number 28-AS-20190913095722
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: SERENITY SENIORS HOME III
FACILITY NUMBER: 198602281
VISIT DATE: 04/18/2022
NARRATIVE
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The investigation revealed the following: S1 indicated R1 had some redness in April 2019 after being hospitalized for an unrelated issue. Facility records also indicate R1 has a history of skin integrity issues. Licensee indicated R1 developed a pressure injury in May 2019 after being hospitalized. In August 2019, facility staff observed R1’s wound became larger. S1 admitted cleaning the wound prior to a medical professional treating it.

On 8/12/19, Physician’s Assistant from Ideal Health visited the facility to conduct a routine wellness check on R1. Physician’s Assistant only observed the skin that was visible and did not check R1’s buttocks because staff did not report any issues with wounds at that time. On 8/13/19, facility staff notified the facility nurse consultant of R1’s wound. However, wound care was not ordered until 8/22/19, when R1’s physician submitted an order to Purity Home Health Services to provide wound care to R1’s sacrum and buttocks area. On 8/22/19, a home health nurse assessed R1’s wounds. The sacral pressure injury was determined to be a Stage IV. On 8/29/19, Purity Home Health Services provided the first wound treatment. The nurse noted the sacrum pressure injury and it’s dressing to be “very dirty with feces”. Facility staff were instructed to reposition R1 every 2 hours. Purity treated the wounds on 8/29/19 and 8/31/19.

On 9/3/19, Omni Wound Physicians began treating R1’s wounds. The pressure injuries were now a Stage IV on the sacral area, a Stage III on the right buttocks and a Stage III on the left buttocks. Omni recommended R1 be evaluated at the hospital. Medical records from Southern California Hospital at Hollywood indicate R1 was admitted to the hospital on 9/5/19 because of a Stage IV pressure injury on the sacral area and acute metabolic encephalopathy. The chief complaint was being lethargic. R1 was admitted to the intensive care unit for septic shock among other conditions. R1 had multiple infections including a UTI and pneumonia.

Facility staff argue home health nurses never left documentation describing the condition of the wound and never notified staff the wounds had worsened. Despite facility staff continuing to provide assistance with R1’s diaper changes.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is 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 held. Administrator, Antoinette Richardson refused to find. A copy of the report and appeal rights were provided. The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49(d); if the department determines the injury of the resident is due to severe neglect.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3969
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20190913095722
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: SERENITY SENIORS HOME III
FACILITY NUMBER: 198602281
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2022
Section Cited
CCR
87615(a)(1)
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Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
(1) Stage 3 and 4 pressure injuries.
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Licensee will certify regulations regarding prohibited health conditions will be followed. Staff will be trained on reporting prohibited health conditions to appropriate parties.
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This deficiency was evidenced by the following: R1 was noted to have redness or a pressure injury around April or May 2019. Staff admitted the wound was worsening in August 2019. Treatment did not start until 8/22/19 when pressure injury was noted as a Stage IV.
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Type A
04/19/2022
Section Cited
CCR
87411(a)
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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.
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Licensee will certify that staff will communicate with home health agencies regarding residents' conditions.
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This deficiency was evidenced by the following: Staff indicated they were unaware of the condition of the wound due to home health agencies not providing documentation. However, it’s the facility staff’s responsibility to obtain the required documentation to confirm their resident is provided adequate 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.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3969
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3