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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602887
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:24:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2020 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20200805163559
FACILITY NAME:SUNRISE ASSISTED LIVING OF HERMOSA BEACHFACILITY NUMBER:
198602887
ADMINISTRATOR:MORRIS, TRAVISFACILITY TYPE:
740
ADDRESS:1837 PACIFIC COAST HWYTELEPHONE:
(310) 937-0959
CITY:HERMOSA BEACHSTATE: CAZIP CODE:
90254
CAPACITY:142CENSUS: 78DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Eric MensahTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Resident sustained a pressure injury while in care.
INVESTIGATION FINDINGS:
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On 11/2/2023 at 1:00 PM, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent complaint visit to deliver the complaint investigation finding of the allegation listed above. LPA conducted a risk assessment with Administrator Eric Mensah who stated the facility is free of Covid-19. LPA explained the purpose of the visit to Administrator Mensah.

Investigations consisted of the following: On 8/7/2020, LPA Montoya conducted a virtual visit and obtained staff roster, resident roster and resident’s (R1) service records. On 12/6/2021, LPA Montoya interviewed staff and residents. LPA obtained additional pertinent records from the facility.

REPORT CONTINUED IN LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
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-20200805163559
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SUNRISE ASSISTED LIVING OF HERMOSA BEACH
FACILITY NUMBER: 198602887
VISIT DATE: 11/02/2023
NARRATIVE
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INVESTIGATIONS REVEALED THE FOLLOWING:

Allegation: Resident sustained a pressure injury while in care

It is alleged resident sustained a pressure injury while in care.

Based on records review, Admission Agreement indicates R1 was admitted to the facility on 5/14/2020. Physician’s Report dated 5/11/2020 and the facility’s Progress Notes dated 5/14/20 indicate R1 has a history of deep tissue pressure injury on the right lateral heel, stage not noted. R1 is non-ambulatory. R1’s Medication Administration Record (MAR) shows facility staff administered Venelax topical ointment from 5/14/2020 through 7/6/2020, 2x day on R1’s right heel for suspected deep tissue pressure injury. During the Torrance Memorial Home Health Nurse’s visit on 5/17/2020, home health nurse instructed caregivers on resident’s Stage 1 Pressure Ulcer to Right Heel to keep off pressure, leave open to air and other measures to prevent skin breakdown. The facility’s progress notes dated 5/17/2020 indicates home health nurse verbalizes nurses will continue to visit once a week and the facility staff/caregivers will continue to assist R1 with repositioning four times per shift and floating right heel on pillow. On 5/22/2020, the facility’s progress notes indicate R1 had a quarter sized open area with surrounding redness on coccyx, care team to continue to apply barrier cream and reposition resident and home health nurse is to visit on 5/23/2020. On 5/31/2020, the facility’s progress notes and the home health notes revealed R1 had developed an open bed sore on the coccyx area. According to the department’s records review, there were no records that R1 received wound care for coccyx from Home Health and no records were found that facility staff repositioned R1 between 5/23/2020 and 5/30/2020. In addition, there was no evidence that the facility made attempts to follow-up on the request for home health services or medical assessment for R1’s coccyx during this period. However, home health continued in providing wound care to RI's right heel. On 6/2/2020, a new home health service for R1's coccyx commenced and it was revealed that R1 developed an unstageable pressure injury on coccyx. On 6/28/2020, Home health notes show R1’s pressure injury in coccyx was at Stage 3 and it progressed to Stage 4 on 7/12/2020. Based on interviews conducted with four out of eight staff (S1, S2, S4 & S8), R1 developed a pressure injury while in care.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met: Due to neglect/lack of supervision, Resident #1 developed an unstageable pressure injury on coccyx, therefore the above allegation “Resident sustained a pressure injury while in care” is found to be SUBSTANTIATED.

REPORT CONTINUED IN LIC 9099-C

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20200805163559
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SUNRISE ASSISTED LIVING OF HERMOSA BEACH
FACILITY NUMBER: 198602887
VISIT DATE: 11/02/2023
NARRATIVE
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Pursuant to Title 22 Division 6 of the California Code of Regulations, following deficiency was cited (refer to LIC 9099-D). Civil penalty assessed.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, “a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to Administrator Eric Mensah.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20200805163559
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SUNRISE ASSISTED LIVING OF HERMOSA BEACH
FACILITY NUMBER: 198602887
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2023
Section Cited
CCR
87612(a)(11)
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87612 Restricted Health Conditions
(a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (11) Wound care as specified in Section 87631. This requirement was not met as evidenced by:
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At the time of visit, R1 was no longer living in the facility.

Administrator Mensah agreed to adhere to the section cited herein and shall submit a self-certification of understanding the Section above. The administrator shall conduct an in-service training on this section to all care staff. POC shall be submitted to Lourdes.montoya@dss.ca.gov by the POC due date, 11/3/2023.
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According to the department’s review, there were no records that R1 received wound care for coccyx from Home Health and no records were found that facility staff repositioned R1 between 5/23/2020 and 5/30/2020 after facility staff found on 5/22/2020 that R1 sustained a quarter sized open area with surrounding redness on coccyx and it developed to an open bed sore on 5/31/2020. In addition, there was no evidence that the facility made attempts to follow-up on the request for home health services or medical assessment for R1’s coccyx during this period. However, home health continued in providing wound care to RI's right heel. On 6/2/2020, a new home health service for R1's coccyx commenced and it was revealed that R1 developed an unstageable pressure injury on coccyx. On 6/28/2020, Home health notes show R1’s pressure injury in coccyx was at Stage 3 and it progressed to Stage 4 on 7/12/2020. Based on interviews conducted with four out of eight staff (S1, S2, S4 & S8), R1 developed a pressure injury while in care. This poses an immediate health, safety and/or personal rights risk to residents 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: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4