198602527-4-11-2021-28-AS-MVAO-C28S4N-20210419133301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602527
Report Date: 04/11/2021
Date Signed: 04/11/2021 01:03:47 PM

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
10/01/2019 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20191001122946

FACILITY NAME:	FIL-AM FOR SENIORS		FACILITY NUMBER:	198602527
ADMINISTRATOR:	CRISS, CRISTINA		FACILITY TYPE:	740
ADDRESS:	1920 N INDIAN HILL BLVD		TELEPHONE:	(562) 547-6833
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 6	DATE:	04/11/2021
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Toby Miclat		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care
Staff inappropriately restraining resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez initiated a telephonic subsequent complaint investigation to deliver investigation 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 Administrator Toby Miclat and Licensee Christina Criss.

Investigation consisted of the following: During the initial visit conducted on 10/10/19, LPA Gonzalez obtained a copy of the Resident Roster and Staff Roster. LPA interviewed Administrator Miclat and Staff 1 (S1). LPA reviewed Resident 1 (R1) facility and hospice file and collected copies of various documents from R1's files which included: Physician's Report for Residential Care Facilities for the Elderly (LIC602A), Identification and Emergency Information (LIC601), Resident Appraisal (LIC603A), Unusual Incident/ Injury Report (LIC 624) dated 9/29/19, Goldberg Hospice Care Visit Documentation dated 8/28/19 - 10/9/19, facility document regarding Postural Supports and Claremont Police Department officer card with report number. LPA also interviewed R1-R2, toured R1's room and interviewed R2's daughter who was visiting during LPA's

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2021

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-20191001122946

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: FIL-AM FOR SENIORS	FACILITY NUMBER: 198602527
	VISIT DATE: 04/11/2021

NARRATIVE

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visit. On 4/11/21, LPA Gonzalez interviewed Licensee Christina Criss and attempted to conduct telephone/ video interviews with R3-4 but was unable to interview the residents due to residents' diagnosis of Major Neurocognitive Disorder. LPA attempted a call to R1's daughter (POA), left a voicemail but did not receive a call back. LPA called Goldberg Hospice and spoke to LVN Katherine Santos and requested/ received documents pertaining to R1 via email. LPA also attempted a call to Staff Estrella Lubi and left a voicemail but did not receive a call back.

The investigation revealed the following: In regard to allegations, Resident sustained unexplained injuries while in care, it is alleged that on 9/26/19 R1 was observed to have red abrasions and bruising on cheeks and bridge of nose. Facility staff stated that R1 kicked facility staff when they were trying to give R1 a shower and facility staff placed a washcloth over R1's face while trying to hold R1 down to finish the shower. On 9/21/19, facility staff reported that R1 had an allergic reaction and also stated that there was no need for hospice agency to come do a check on R1. Interview conducted with Administrator Miclat revealed that on 9/21/19 as Staff Lubi and Zapanta were performing morning care which included a sponge/ towel bath, R1 became resistive and combative at the same time that Staff Lubi was wiping R1's face. Interview conducted with Staff Zapanta revealed that as he was assisting Staff Lubi with R1's morning care, R1 became very combative. He stated that R1 is usually very combative and resistive and R1 will kick and swing arms everywhere. Staff Zapanta stated that as Staff Lubi was wiping R1's face, resident became combative and began moving their face from left to right and when Staff Lubi immediately removed the face towel from R1's face they noticed that R1s face was red and bleeding from nose was observed. Interview with Administrator Miclat also revealed that when hospice agency visited and observed the redness/ bruising on R1's face they questioned Staff Hernandez about the bruising and Staff who has a language barrier could not properly answer the hospice nurse's questions properly and stated to nurse that a staff "put a towel on face" and she believes that is were they confusion arose. Staff Hernandez was not at the facility when the incident occurred. Staff Zapanta denies that a towel was placed over R1's face but that a towel was used to wipe R1's face. Interview with Licensee Criss revealed that R1 is not under hospice care anymore and hospice was terminated on 12/31/19. Mrs. Criss also stated that R1's behavior is more subdued and R1 seems to have acclimated to the facility. Interview conducted with R2's daughter on 10/10/19 revealed that she visits R2 a few times per week and she has not noticed anything that causes any concerns. She stated that staff are very attentive and treat the residents wonderfully. She stated that she visits at different times during the day including the morning and has observed staff to be gentle and patient as they provide care to the residents and are getting

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20191001122946

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: FIL-AM FOR SENIORS	FACILITY NUMBER: 198602527
	VISIT DATE: 04/11/2021

NARRATIVE

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them ready for the day. LPA also reviewed Goldberg Hospice notes and observed that R1 was combative and at times and hospice staff had to request for facility staff to assist with R1's bath due to R1's combativeness and flailing of arms and legs. LPA attempted to interview R1-R4 but was not able to properly interview residents as they have a diagnosis of Major Neurocognitive Disorder. Based on interviews conducted with facility staff, R2's daughter and review of documents, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Staff inappropriately restraining resident while in care, it is alleged that facility staff used restraints on R1 without a doctor's order. Interviews with Administrator Miclat, Licensee Christina Criss revealed that restraints were not used on R1 and stated that R1 only had a doctor's order for a Lap Buddy which is used to assist R1 with posture while R1 uses wheelchair. Staff deny that any other types of restraints are ever used on R1 or any other resident and if any are used there is a doctor's order on file. During LPA's visit on 10/10/19, LPA did not observe any items that might be used as a restraint. LPA conducted a tour of R1's room and did not notice any restraint devices. LPA also observed R1 sitting on their wheelchair and LPA did observe a Lap buddy. Staff Zapanta denied that any other restraints are used on any residents at facility. Interview with R2's family member also revealed that they have not observed anything that causes any concerns and they are satisfied with the services and treatment that their loved one receives at the facility. Interview conducted with Goldberg Hospice LVN Santos revealed that the only order for R1 on file is for the Lap Buddy and also stated that R1's hospice agency services were terminated on 12/31/19 due to R1 no longer meeting criteria for continued hospice care. R1's symptoms managed with no indication of decline, no weight loss, responding well to nutritional supplements and weight gain. Discharge care plan meeting was conducted with facility staff and R1's family who all verbalized understanding. LPA attempted to interview R1 but was not successful as R1 has a diagnosis of Major Neurocognitive Disorder. Based on the investigation and supporting information obtained, this allegation is not corroborated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Due to measures implemented due to COVID-19, exit interview was conducted with Administrator Toby Miclat via telephone. A copy of the report was sent via email for signature. A hard copy with signature is on file.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2021

LIC9099 (FAS) - (06/04)

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