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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603049
Report Date: 06/24/2022
Date Signed: 06/24/2022 04:33:17 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
03/19/2021 and conducted by Evaluator Jey Cardenas
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210319085122
FACILITY NAME:MATHARU HOME #1FACILITY NUMBER:
198603049
ADMINISTRATOR:GALEANO, ADRIANAFACILITY TYPE:
735
ADDRESS:15227 ROSELLE AVETELEPHONE:
(310) 328-8482
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY:6CENSUS: 2DATE:
06/24/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Adriana GalenaoTIME COMPLETED:
04:33 PM
ALLEGATION(S):
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Resident developed a stage 4 pressure injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Jey Cardenas conducted a subsequent complaint visit to deliver complaint findings for the allegation: Resident developed a stage 4 pressure injury while in care. Upon arrival at the facility LPA met with DSP staff, Pineda and conducted a risk assessment, based on the assessment; the facility is clear of Covid-19 infection. LPA was later met with Administrator, Adriana Galeano and the purpose of today’s visit was explained.

The investigation consisted of the following: On 3/22/21, LPA Jones conducted a complaint tele-visit with administrator, Adriana Galeano. Jones toured the facility and requested copies of staff and client rosters, Client#1 (C1) admission agreement, physician’s report, Unusual Incident Report (UIR) and body check chart. Community Care Licensing Division’s Investigations Branch (IB) Investigator Brian Slatic conducted a full investigation into the alleged neglect.

It is being alleged that On 3/16/21 C1 was admitted to the hospital for Hypernatremia, during admission
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
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 5
Control Number 11-AS-20210319085122
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: MATHARU HOME #1
FACILITY NUMBER: 198603049
VISIT DATE: 06/24/2022
NARRATIVE
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(continued pg2)

one (1) pressure injury to coccyx area was observed. Facility staff failed to notice change in C1’s condition.

IB’s investigation revealed the following: Per Slatic review of facility records: Unusual Incident Report (UIR) on 3/16/21 House manager contacted the facility RN to report that C1 was refusing meals and was lethargic. C1 primary care physician was unavailable, therefore C1 was taken to Little Company of Mary Medical Center -Torrance Emergency Room for an evaluation. Physician’s Report dated 2/1/2021 lists C1’s primary diagnoses as Profound intellectual disability, Parkinson’s disease, and diabetes. Secondary diagnoses include psychosis and generalized muscle weakness. C1 is not able to transfer independently to and from bed. Per most recent Individual Program Plan (IPP) is dated 12/3/20, C1 requires total assistance with Activities of Daily Living (ADL) skills such as dressing, bathing, hygiene, toileting, and grooming. The IPP nursing report dated 1/15/20 does not document any information about skin integrity issues. Per Body check chart for the period of 2/16/21 through 3/16/21 show that C1 was checked three times per day; no injuries or concerns were noted during this period.

Per Slatic review of the Little Company of Mary Medical Center -Torrance medical records: On 3/16/21 at 1243 hours C1 was brought Little Company of Mary Medical Center in a wheelchair due to decreased oral intake and weakness. At 1302 hours C1 was admitted to the Emergency Department. The initial exam found a Stage III decubitus pressure injury the size of a silver dollar on coccyx area. On 3/17/21 at 0229 hours, the notes indicate pressure injury was upgraded to a stage IV located on the coccyx area. On 3/22/21 at 1120 hours the pressure injury was listed as unstageable. C1 was noted to be bedbound, with Parkinson’s disease, dementia, with “functional quadriplegia”.

Per Slatic interviews; On 6/17/21 Slatic interviewed facility registered nurse, he contends that C1 did not leave the facility with a Stage 3 or Stage 4 pressure wound. On 6/24/21 Slatic interviewed caregiver S2 who denies observing skin breakdown. On 6/28/21 Slatic interviewed caregiver S3 who denies observing skin breakdown. On 3/22/21 LPA Jones interviewed Adriana Galeano who stated that staff conduct body checks 3 times a day and a pressure injury was never observed.

Based on interviews and records reviewed, the preponderance of evidence standard has been met. Hospital records dated 3/16/21 to 3/22/21 confirmed the initial diagnosis of a stage III pressure injury on the coccyx area during the admission. Pressure injury on the coccyx was later upgraded to a stage IV upon

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 11-AS-20210319085122
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: MATHARU HOME #1
FACILITY NUMBER: 198603049
VISIT DATE: 06/24/2022
NARRATIVE
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(continued pg3)

further examination. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. copy of this report and appeal rights provided to facility representative. Immediate civil penalty issued on today, appeal rights provided. Exit interview conducted

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1548(f)(1)(A) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 243 of the Penal Code, to a resident at an adult residential facility, social rehabilitation facility, enhanced behavioral supports home licensed as an adult residential facility, adult residential facility for persons with special health care needs, or community crisis home, the civil penalty shall be ten thousand dollars ($10,000).

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210319085122
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: MATHARU HOME #1
FACILITY NUMBER: 198603049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2022
Section Cited
HSC
1548(f)(1)(A)
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For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury... This requirement not met as evidenced by: Hospital records dated 3/16/21 to 3/22/21
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Submit written plan on how facility plans to to provide traiing on identification, prevention, and treatment of pressure injuries or skin break down. Plan should include daily body checks and charting.
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confirmed C1s diagnosis of pressure injury stage 4 upon being admitted to hospital. This poses an immediate health and safety risk to clients in care.
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Type B
06/27/2022
Section Cited
CCR
80072(a)(2)
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Personal rights To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement not met as evidenced by: Medical records obtained revaled C1 was retained with pressure injuries, no home health or hospice involved.
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Submit self certification indicating title 22 personal rights regulations have been reviewed and understood; self attestation shall be submitted to LPA by POC date.
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This poses a potential personal rights risk to clients 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20210319085122
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: MATHARU HOME #1
FACILITY NUMBER: 198603049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2022
Section Cited
CCR
80064(a)(2)
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Knowledge of the requirements for providing the type of care and supervision needed by clients, including ability to communicate...This requirement not met as evidenced by: C1 was observed with pressure injuries at the hospital,
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Administrator shall review the performance of each staff members assisting the clients and ensure that the clients are receiving services per their care plan. Writetn plan to be submitted to LPA by POC date.
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change of condition was no noted. This poses a potential health and safety risk to clients in care.
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Type B
06/27/2022
Section Cited
CCR
80091(a)(4)
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Stage 3 and 4 dermal ulcers...This requirement not met as evidenced by: C1 has documented stage 4 pressure injuries, client was retained at facility. This poses a potential health and safety risk to clients in care.
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The facility will review the regulation regarding prohibited health conditions and will certify the regulations have been understood. Certification will be provided to licensing by the POC due date.
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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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5