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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602583
Report Date: 06/04/2021
Date Signed: 06/04/2021 02:16:02 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
01/14/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20210114102645
FACILITY NAME:OAK PARK MANOR, LPFACILITY NUMBER:
198602583
ADMINISTRATOR:JOHNSON, SABRINAFACILITY TYPE:
740
ADDRESS:501 S COLLEGE AVENUETELEPHONE:
(909) 626-0117
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:68CENSUS: 37DATE:
06/04/2021
UNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Donell Clark - Marketing DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not contact the authorized representative in a timely manner about resident change in health.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) Mary Flores conducted a unannounced complaint investigation regarding the above allegation(s). LPA Flores met with Donell Clark, Marketing Director.

The investigation consisted of the following: LPA Flores conducted a telephone interview with the administrator, and requested copies of staff/resident roster, Physician's Report, Admission Agreement, Medication Sheets for December and January, Nurse/Caregivers notes for December and January, Discharge Notes for Hospitalizations, and Hospice Notes if apply for Residents #1(R1),#2,#3,#4#5,#6 to be emailed. On 1/19/21 LPA interviewed R1"s responsible party. On 3/16/21 LPA requested R1's death certificate. On 4/8/21 LPA submitted a request to our Investigation Branch (IB) to subpoena documents from Gardens of El Monte and Calcare Home Health Agency. On 5/6/21 LPA recieved IB subpoena documents. On 5/7/21 LPA Flores reviewed documents received for R1. On 6/4/21 LPA Flores conducted a visit at the facility requested staff/resident roster, and reviewed R1's file. (CONTINUED LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
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 5
Control Number 28-AS-20210114102645
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: OAK PARK MANOR, LP
FACILITY NUMBER: 198602583
VISIT DATE: 06/04/2021
NARRATIVE
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The investigation revealed the following: Regarding allegation; Facility did not contact the authorized representative in a timely manner about resident change in health. It is alleged that authorize representative received a call from a local hospital and that R1's roommate was positive for Covid and was moved to another area of the facility but that R1 was not moved but then R1 was moved at a later date but was not positive and AR was not notified of move. Interview with authorized representative determined that AR was notified of R1's hospitalization, change in condition, and urinary track infection (UTI) on 12/13/20 from hospital after receiving call from hospital first and later a call from facility on 12/13/20. AR also stated to not be notify of R1 being moved to the cottage where facility was isolating positive COVID residents. AR also stated to not be notify that R1 was positive for COVID 19 prior to 12/13/21. AR found that R1 was being transfer to Gardens of El Monte on 12/17/21 as it was happening and not consulted of transfer. Based on interview with administrator R1 was moved to cottage and was positive for COVID 19 asymptomatic at the beginning and develop symptoms after. R1 was send to the hospital on 12/13/20 due to change in condition. Upon R1's discharge and arriving at the facility. Consultant in charge at the time made the decision to transfer R1 to Gardens of El Monte as facility could not provide proper care for resident. After reviewing R1's file on 6/4/21 LPA Flores noted that on doctor's communication notes on 7/22/20 facility notified R1's doctor and noted to have notify AR on 7/22/20 at 10:56pm. Doctor's communication notes provided to LPA on 3/23/20 dated 12/6/21 notes transfer of R1 to the cottage due to COVID 19. However there are no notes of communicating transfer to AR. Current Administrator provided text message communication screen shots with AR in which notes Administrator had communication on 12/14/20,12/16/20, 12/17/20 but there is no mention of change in condition in text message. Medical records reviewed for hospital discharge R1 was discharge to Oak Park Manor on 12/17/21 same day R1 was admitted to Gardens of El Monte. R1's file does not contain R1's COVID test results and it is unknown when R1 tested positive for COVID 19. Facility Narrative Charting Notes show for 12/9/20 through 12/12/20 - R1 "isn't feeling well". On 12/11/20 and 12/12/20 notes for R1 "moaning and coughing" in addition to "Resident isn't feeling well".

Based on LPA's document review and interviews conducted the preponderance of evidence standard has been met, therefore the allegation(s) is SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Donell Clark, marketing director and a copy of this report, LIC 9099D, and appeal rights were provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
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 5
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
01/14/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20210114102645

FACILITY NAME:OAK PARK MANOR, LPFACILITY NUMBER:
198602583
ADMINISTRATOR:JOHNSON, SABRINAFACILITY TYPE:
740
ADDRESS:501 S COLLEGE AVENUETELEPHONE:
(909) 626-0117
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:68CENSUS: 37DATE:
06/04/2021
UNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Donell Clark - Marketing DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff failed to seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) Mary Flores conducted a unannounced complaint investigation regarding the above allegation(s). LPA Flores met with Donell Clark, Marketing Director.

The investigation consisted of the following: LPA Flores conducted a telephone interview with the administrator, and requested copies of staff/resident roster, Physician's Report, Admission Agreement, Medication Sheets for December and January, Nurse/Caregivers notes for December and January, Discharge Notes for Hospitalizations, and Hospice Notes if apply for Residents #1(R1),#2,#3,#4#5,#6 to be emailed. On 1/19/21 LPA interviewed R1"s responsible party. On 3/16/21 LPA requested R1's death certificate. On 4/8/21 LPA submitted a request to our Investigation Branch (IB) to subpoena documents from Gardens of El Monte and Calcare Home Health Agency. On 5/6/21 LPA recieved IB subpoena documents. On 5/7/21 LPA Flores reviewed documents received for R1. On 6/4/21 LPA Flores conducted a visit at the facility requested staff/resident roster, and reviewed R1's file. (CONTINUED LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
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: 3 of 5
Control Number 28-AS-20210114102645
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: OAK PARK MANOR, LP
FACILITY NUMBER: 198602583
VISIT DATE: 06/04/2021
NARRATIVE
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The investigation revealed the following: Regarding allegation; Staff failed to seek medical attention in a timely manner. It is alleged R1 was in the hospital diagnosed with a severe UTI. Hospital stated that it was severe, and the infection was spreading within to other organs. Documents reviewed determined the following R1 began to receive services with Calcare Home Health Agency on 2/3/20 with the following diagnoses: Unspecified protein -calorie Malnutrition, age related physical debility, other chronic pain, Alzheimer's disease, Bilateral primary osteoarthritis of knee, abnormalities of gait and mobility, other unspecified urinary incontinence, heart disease of native coronary artery, personal history of urinary tract infections, primary insomnia, unspecified superficial injury of scalp, history of falling in order of severity. Calcare Home Health notes on 9/29/20 stated unmet goal (7): Patient will be without signs or symptoms of UTI (...) during this episode. Goal term: long Target date: 11/28/20. Calcare Home Health notes on 11/24/20 stated Met goals (6) Patient will be without signs or symptoms of UTI (...) during this episode. Goal term: long Target date: 11/28/20 and Reason for Discharge marked as goals met. R1 was discharge from Home Health care on 11/24/20 based on documents reviewed. R1 was admitted to Pomona Valley Hospital Medical Center on 12/13/20 notes state: Chief Complaint: ...for weakness and fatigue after new Dx of COVID +, Mentation baseline.; Reason for Consultation: COVID.; Consultation notes: ceftraxone for UTI pending culture.; Diagnosis/Chief Complaint(s) UTI COVID. Pomona Valley Hospital Medical Center Discharge/Transfer Documentation: Document Type: Discharge Instructions; Sign Information: (12/16/2020 15:30PST). Your Diagnosis: Urinary Tract infection, weakness, Elevated troponin level, metabolic encephalopathy, weakness. Facility's Narrative Charting for 9/14/20 to 1/9/21 R1's notes residents checks and there are no notes related to UTI. Based on the documents reviewed it is uncertain when R1 developed UTI.

Based on LPA's document review and interviews conducted the preponderance of evidence standard has been met, therefore the allegation(s) is UNSUBSTANTIATED.

Exit interview was conducted with Donell Clark, marketing director and a copy of this report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
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 5
Control Number 28-AS-20210114102645
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: OAK PARK MANOR, LP
FACILITY NUMBER: 198602583
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2021
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee shall...: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidence by:
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Administrator will ensure to notify of any change in condition, transfers or any issues related to residents at all times. Administrator to submit LIC9098 certifying facility will follow reporting requirements and any in-service training provided by 6/18/21.
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Based on LPA's interviews and documents reviewed Administrator did not ensure R1's authorized representative was notified of R1's change in condition, transfer within the facility, tranfer to Skill Nursing prior to each happening which poses a potential 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.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
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 5