198603109-1-25-2024-28-AS-RORN-CZYU82-20240130142049

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603109
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:52:13 PM

Unsubstantiated

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
01/16/2024 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240116103521

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: 6	DATE:	01/25/2024
		UNANNOUNCED	TIME BEGAN:	08:47 AM
MET WITH:	Jamore Splung - Caregiver		TIME COMPLETED:	03:06 PM

ALLEGATION(S):

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Staff did not prevent a resident from falling, resulting in resident becoming wheel chair bound.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegation. LPA met with Jamore Splung (Caregiver) and explained the reason for the visit.

The investigation consisted of the following: LPA Mora reviewed Resident 1 (R1) entire file, and interviewed Administrator, Staff 1 - Staff 2 (S1 - S2), Resident 1 - Resident 6 (R1 - R6), R1's Responsible Representative 1, and R1's Responsible Representative 2.

The investigation revealed the following: regarding the allegation "staff did not prevent a resident from falling, resulting in resident becoming wheel chair bound.", it is alleged that staff are not properly taking care of R1 which led to a fall and caused R1 to be wheelchair bound.

(Continued to LIC 9099-C)

Unsubstantiated

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: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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-20240116103521

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: 01/25/2024

NARRATIVE

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Administrator and staff interviewed denied the allegation and stated that R1 has not had a fall at this facility. Administrator stated that in December 2021 R1 was hospitalized due to GI issues and had surgery, and returned to the facility in January 2022 with a wheelchair. Home health provided physical therapy for a couple of weeks, but the resident remained wheelchair bound. LPA attempted to interview R1, but R1 stated does not remember having a fall and only commented about having knee surgeries. R1 was unable to provide any other details regarding the surgeries or the reason why R1 is wheelchair bound. Review of R1's file revealed the following: R1 was admitted to this facility on 09/15/2021. Physician report dated 09/08/2021 states that R1 is ambulatory and may use walker or wheelchair. Preplacement Appraisal dated 09/14/21 states that R1 had left knee surgery on 08/30/2021 and walks with a walker. The Appraisal/Needs and Service Plan dated 09/15/2021 also state that R1 walks with a walker. Incident report dated 12/10/2021 states that R1 was sent to the hospital on 12/09/2021 due to black vomit and stool. Incident report dated 12/22/2021 states that R1 returned back to the facility on 12/15/2021 with lots of pain on the left knee and ended being sent again to the hospital on 12/18/2021 for black vomit and stool again. Incident report dated 01/07/2022 states that R1 returned to the facility after being hospitalized from 12/18/2021 to 01/07/2022 and had a surgical intervention over the course of GI bleeding. The Appraisal/Needs and Service Plan dated 09/15/2022 states that R1 is wheelchair bound. There are no records or incident reports stating that R1 had a fall. R1's Responsible Representative 1 confirmed that R1 returned to the facility from the hospital on a wheelchair in January 2022 after having gallbladder surgery and since then has been on a wheelchair. There is no records or evidence to support that the resident is wheelchair bound due to a fall.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview held and a copy of the report 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: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

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