198603109-4-26-2023-28-AS-RORN-CR9T33-20230426142139

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603109
Report Date: 04/26/2023
Date Signed: 04/26/2023 09:25:52 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/12/2019 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20191112124020

FACILITY NAME:	GRACE BLOSSOM CARE		FACILITY NUMBER:	198603109
ADMINISTRATOR:	IKPEAMAEZE, LILIAN		FACILITY TYPE:	740
ADDRESS:	20430 HARVEST AVE		TELEPHONE:	(951) 816-1077
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90715
CAPACITY:	6	CENSUS: 5	DATE:	04/26/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Lilian Ikpeamaeze - Administrator		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Resident developed a pressure injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to provide clarification and issue one more deficiency that was not included in the original report dated 04/29/2021 written by LPA Nicol Wesley. LPA met with Lilian Ikpeamaeze (Administrator) and explained the reason for the visit.

After review, your appeal disputes the statement by Licensing Program Analyst Nicol Wesley on the complaint investigation report dated April 29, 2021, that Resident #1 (R1) was admitted into the facility with no bedsores or pressure injuries. Upon review of records, interviews and statements made by family members, it was determined that Resident #1 (R1) had an existing pressure ulcer of sacrum stage 2 at the time of admission on October 15, 2019. This was also evidenced by the hospital discharge notes that included pressure ulcer instructions and the pictures provided with the appeal dated October 15, 2019 of the injury in question.
(Continued to LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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-20191112124020

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRACE BLOSSOM CARE	FACILITY NUMBER: 198603109
	VISIT DATE: 04/26/2023

NARRATIVE

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Resident #1 (R1) was observed to have a stage 3 sacral pressure ulcer on February 13, 2020 during a visit from the home health agency. This diagnosis was confirmed during a doctor’s visit on February 14, 2020 yet the facility readmitted the resident to the facility knowing that the resident had a prohibited health condition and was not on hospice. This is a violation of Section 87615(a)(1) Prohibited Health Conditions.

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

Exit interview held and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20191112124020

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRACE BLOSSOM CARE	FACILITY NUMBER: 198603109
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/27/2023 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	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. This requirement was not met by evidence of:	1 2 3 4 5 6 7	The administrator is to send self-certification within 24 hours that the facility will comply with Section 87615 at all times.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, on February 14, 2020 during a doctor’s appointment, it was confirmed that the resident had a stage 3 wound which is a prohibited health condition yet the resident returned to the facility the same day, which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

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