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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603109
Report Date: 04/29/2021
Date Signed: 05/04/2021 02:49:58 PM

Substantiated


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
11/12/2019 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20191112124020
FACILITY NAME:GRACE BLOSSOM CAREFACILITY NUMBER:
198603109
ADMINISTRATOR:IKPEAMAEZE, LILIANFACILITY TYPE:
740
ADDRESS:20430 HARVEST AVETELEPHONE:
(951) 816-1077
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY:6CENSUS: DATE:
04/29/2021
UNANNOUNCEDTIME BEGAN:
05:21 PM
MET WITH:Lilian IkpeamaezeTIME COMPLETED:
05:22 PM
ALLEGATION(S):
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Resident developed a pressure injury while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley initiated a aubsequent complaint investigation for the allegation listed above. 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 Lilian Ikpeamaeze.

Investigation consisted of the following: LPA observed the residents and toured the facility. LPA did not observed there to be any immediate health and safety concerns. LPA Wesley reviewed and requested copies of specific documents, and interviewed the Administrator, staff, and resident #1's(R1) family member.

Investigation revealed the following: On 10/15/19 R1 was admitted into the facility with no bedsores/pressure injuries(PI) upon admission. On 11/10/19 R1 was admitted into the hospital and during that time it was communicated that R1 had fallen and the staff did not reposition R1 every two hours as requested.
Continued on LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
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-20191112124020
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: GRACE BLOSSOM CARE
FACILITY NUMBER: 198603109
VISIT DATE: 04/29/2021
NARRATIVE
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Hospital medical staff observed that R1 had a stage II PI in the Sacrum area. The hospital referred R1 to a Home Health agency for wound care. Home Health agency staff went to the facility and provided wound care to R1. Home Health advised that during the course of wound care treatment, the wound started to develop an odor, so Home Health requested for staff to move and/or reposition R1. There was also documentation that indicated R1 was in so much pain they would cry so Home Health recommended for R1's dressing be changed two or three times daily as they observed R1's wound dressing to be saturated with urine and bowel, and also for staff to reposition R1 every 2 hours to prevent the PI from getting worse. Home Health also recommended for staff to request pain medication for R1 to assist with the pain. On 02/14/20 R1 attended their doctors appointment for evaluation and wound care. The treating Physician discovered that R1's PI was at a stage III which had to be packed, as it has grown in size and gotten deeper. On 02/18/20 R1's PI was unstageable. LPA Wesley conducted interviewed the Administrator, staff, R1's family and other parties, and it was communicated that there were no concerns that R1 was neglected, but a dissatisfaction that the facility staff were not providing adequate wound care for R1. LPA Wesley interviewed the Administrator Lilian Ikpeamaeze who said there are 3 residents who are on Hospice and 1 resident who receives assistance from a home health agency and she advised that she and the staff provides the resident's with proper assistance and follow the instructions from the Hospice and Home Health Providers. LPA Wesley interviewed staff #1 and staff #2 who also said they provided proper assistance to the residents in care and also provides assistance with keeping the resident's wound dressing clean and dry .


Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Immediate Civil Penalties will be issued today, in the amount of $500.00 due to resident sustaining an unstageable Pressure Injury while under the facility care.

A telephonic exit interview was conducted with Administrator Lilian Ikpeamaeze, and a hard copy was provided via email to obtain signature.

**This is a corrected copy of the LIC 9099/LIC 9099C/LIC 9099D that was provided to Administrator Lilian Ikpeamaeze on 04/29/21 to obtain signatures.**
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
CCLD Regional Office, 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: 04/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/26/2021
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care; A plan for incidental medical ... shall be developed by each facility. The plan shall encourage routine medical... and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and...
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Licensee/Administrator to conduct staff training regarding how staff will ensure they have adequate knowledge in obtaining medical care for residents in a timely manner including communication with Home Health and Hospice care agencies prior to them leaving the facility.
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appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: On 11/10/19 Medical reports/ER documentation confirmed that R1 had a stage 2 PI(Sacrum), ComCar Home health provdied daily wound care and observed R1's dressing to be saturated in urine and
bowel, suggested for facility staff to change
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Send proof of correction: Training topics and sign in sheet to CCLD Attn: Nicol Wesley by POC date 05/10/21.
Request Denied
Type A
04/26/2021
Section Cited
CCR
87465(a)(1)
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**Citation Continued**
dressing and reposition the resident every two hours, to avoid the PI from become worse. On 02/14/20 R1's physician advised that R1's PI was a stage III, packed the wound, and provided care instructions. On 02/18/20 medical records were obtain from
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the hospitial indicating R1 PI was unstageable and the Home Health Agency sent a referral to their RN requesting recommending that R1 be referred to receive a higher level of care.

**Immediate Civil Penalty issued doe $500.**
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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: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
CCLD Regional Office, 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: 04/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2021
Section Cited
CCR
87405(A)(1)-(7)
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Administrator - Qualifications and Duties.
All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the accountable for management and...,
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Licensee/Administrator to review title 22 regulations and conduct staff training regarding how staff will ensure the Administrator and staff are knowledgeable in providing appropriate care and supervision as well as documenting any changes in their health condition including but not limited to for residents in a timely manner.
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The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply...,This requirement was not met as evidenced by: It was discovered that the administrator did not seek medical attention for R1 after staff
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Send proof of correction: Training topics and sign in sheet to CCLD Attn: Nicol Wesley by POC date 05/10/21.
Type A
05/10/2021
Section Cited
CCR
87405(a)(1)-(7)
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**Citation Continued**
discovered the PI had worsened and there was no documentation and no evidence to prove the Administrator or staff documents the resident's activity or change in health condition/observation of Pressure Injuries.
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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: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
CCLD Regional Office, 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: 04/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2021
Section Cited
CCR
87211(a)(1)(A)-(D)
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Reporting Requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within
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The licensee/administrator will conduct an in-service training for all staff regarding reporting requirements. The facility will submit training logs to CCLD/ATtn Nicol Wesley by POC date 4/20/2021.
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seven days of the occurrence of any of the events specified in (A) through (D)......
This requirement has not been met as evdience by: The Licensee/Administrator failed to submit incident reports for R1 on 11/10/19 and 02/14/20.
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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: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5