198603161-6-16-2021-28-AS-MVAO-C4FQ3S-20210629114915

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603161
Report Date: 06/16/2021
Date Signed: 06/16/2021 01:48:38 PM

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
07/07/2020 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200707114120

FACILITY NAME:	CALIFORNIA MISSION INN		FACILITY NUMBER:	198603161
ADMINISTRATOR:	LOPEZ, GINA		FACILITY TYPE:	740
ADDRESS:	8417 MISSION DR		TELEPHONE:	(626) 287-0438
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY:	85	CENSUS: 43	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Tyler Cheney, Operations Director		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Facility staff failed to give resident medication as prescribed.
Facility staff failed to meet resident's hygiene needs.
Facility staff does not respond timely to resident's requests for assistance or at all.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Noemi Galarza conducted a subsequent complaint investigation visit to deliver findings.The purpose of the visit was explained to Operations Director Tyler Cheney.

The investigation consisted of the following: Interviews with staff (S1-S8) and residents (R1- R7). Due to the COVID-19 pandemic, on 7/13/2020 a telephonic complaint visit was completed. On 5/14/2021, an in-person visit was conducted; which included review of resident (R1's) file documents, medication review/audit of four (4) randomnly selected residents, and a physical plant tour of all floors, resident rooms, common areas, and medication room. LPA tested the call signal sytem in 11 rooms, of which 5 did not have an operating signal system. In addition, the facility only had 1 working pager used by staff that gets calls from the signal system. The following documents were obtained: Identification and Emergency Information, Preplacement Appraisal Information, Appraisal/Needs and Services Plan, Physician Report, Medication Administration Records (MAR's) for months May 2020- July 2020, Admission Agreement, resident roster, LIC 500 Personnel Report, incident report (7/5/20), partial shower log records, LIC 500 Personnel Report, resident roster, caregiver notes, and hospital discharge documents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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-20200707114120

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: CALIFORNIA MISSION INN	FACILITY NUMBER: 198603161
	VISIT DATE: 06/16/2021

NARRATIVE

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Allegation: "Facility staff failed to give resident medication as prescribed." Based on document review and interviews conducted the findings indicate resident (R1) was prescribed Furosemide [Lasix] tablet 20 mg medication. Per staff interviews, the medication was filled on time and administered as directed. Staff stated medication refills are ordered one (1) week before the medication ends. It was reported that resident (R1) is compliant with medications and never communicated medication issues with med-tech staff.

A total of seven (7) residents were interviewed. Two residents stated they have not been medications as prescribed. One resident stated that on several occasions one medication that is to be taken once weekly was not administered. Another resident stated that during Summer 2020 staff failed to administer medications as prescribed. A total of eight (8) staff were interviewed. The facility has new Administration staff that stated they are unaware of medication issues/errors that allegedly occurred during June 2020- July 2020. All staff denied the allegation.

On 5/14/2021 during the random medication review/audit a medication error was observed. During medication review resident (R8) was missing medication Furosemide 80 mg. The two med-tech staff (S9 & S10) that assisted during the medication review did not find the missing medication. Neither staff had an explanation or documentation to show the reason the medication was not available and/or discharged by a physician. At the end of visit dated 5/14/21 staff (S9) stated resident (R8's) hospice agency was contacted and it was confirmed the facility failed to request R8's medication refill on time.

Allegation: "Facility staff failed to meet resident's hygiene needs." Based on records review and observation resident (R1) was scheduled to receive sponge baths due to non-ambulatory physical condition. The Pre-Placement Appraisal stated resident needs help with bathing. The Appraisal Needs and Services Plan did not include bathing assistance notes. However, R1 is wheelchair bound, unable to bathe on its own, and needs incontinence care. Three (3) residents reported not receiving bathing assistance regularly and as needed. Staff interviewed denied negligence in meeting resident's hygiene needs. One (1) staff stated R1 received sponge baths twice a week. Other staff interviewed stated they had no knowledge of R1's bathing schedule or whether the resident failed to get sponge baths per shower log schedule and as needed.

See- LIC 9099C for report continuation.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20200707114120

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: CALIFORNIA MISSION INN	FACILITY NUMBER: 198603161
	VISIT DATE: 06/16/2021

NARRATIVE

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Continuation- Allegation "Facility staff failed to meet resident's hygiene needs."
Full shower log records were requested. Only some shower log schedules were obtained. Current Administration staff stated they were unable to find old (2020) and recent (2021) shower log records. Per record review, resident (R1) requires incontinence care and bathing assistance. Resident (R1) stated staff provide a bed pan and tell the resident to stay in bed. Resident reported that incontinence care is provided in the morning and is provided incontinence care again until approximately 8pm -9pm. Resident (R1) requests incontinence assistance but often waits a long time because due to body size two-person staff assist is needed. Staff stated it takes approximately 30 minutes to provide incontinence care. Staff acknowledged there were staff shortages during Summer 2020. In addition, during Summer 2020 resident (R1) did not have in place a physician order for a Hoyer Lift.

Allegation: "Facility staff does not respond timely to resident's requests for assistance or at all." Based on observations made during facility visit inspection dated 5/14/2021 there is evidence indicating staff do not respond to resident's requests for assistance. LPA conducted random testing of call signal system in resident rooms. A total of 11 rooms were inspected. Out of the 11 rooms five (5) rooms did not have operable call signal system in the room i.e. bathroom wall unit, or pendants accessible to non-ambulatory or bedridden residents. Some rooms did not have any signal system in the rooms, and/or did not have a call signal pendant accessible to them. Room 165 call signal system was tested at 1:15 pm, but staff responded to the pendant call until 1:47 pm. Staff were observed to be across the hall from room 165 during the call light system test and did not respond to the request for assistance. At the time of the visit the facility had a pager system of which only one (1) pager was observed to be operable. It is alleged that it takes hours for staff to respond to call signal system. Resident interviews revealed staff response time to assistance requests at times takes longer than 10 minutes or hours.

Deficiencies are being cited based on LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC 9099D.

An exit interview was conducted and Plans of Correction were reviewed and developed with Administration staff. A copy of the report and appeal rights were discussed and left with Operations Director Tyler Cheney.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20200707114120

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: CALIFORNIA MISSION INN	FACILITY NUMBER: 198603161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/18/2021 Section Cited CCR 87465)(c)(2)	1 2 3 4 5 6 7	87465)(c)(2). Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Operations Director agreed to submit a written plan of correction. All med-tech and direct care staff will be provided medication administration training. This training shall be provided by a pharmacy and/or registered nurse. Submit proof of training by POC due date.
	8 9 10 11 12 13 14	Based on records review/audit of randomly selected resident's medications on 5/14/2021, LPA observed a medication error. Resident (R8) was missing medication Furosemide 80 mg. The two med-tech staff (S9 & S10) that assisted during the medication review did not find the missing medication, and later that day confirmed the facility failed to order the medication refill in a timely manner or administered as directed.	8 9 10 11 12 13 14
Type A 07/14/2021 Section Cited CCR 87303(i)(1)	1 2 3 4 5 6 7	87303(i)(1). Maintenance and Operation. Facilities licensed for 16 or more and/or facilities that have separate floors or buildings shall have a signal system which meets specified requirements.Operate from each resident's living unit. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Operations Director stated the facility signal system is presently being replaced with a new system. Wiring was completed yesterday 6/15/21. Installation of the new signal system will be completed by mid July 2021. Administrator agreed to submit proof of correction i.e. invoice of completed system installation by POC due date. If an extension to the POC is needed, a written request must be submitted to LPA before due date.
	8 9 10 11 12 13 14	Based on physical plant observations on 5/14/21 the facility failed to have an operable call signal system in all resident rooms. Five (5) out of 11 rooms that had the signal system tested were missing the system and/or the signal pendants were not accessible to non-ambulatory residents. This poses an immediate health and safety risk.	8 9 10 11 12 13 14

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 28-AS-20200707114120

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: CALIFORNIA MISSION INN	FACILITY NUMBER: 198603161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/28/2021 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	87464(f)(4) Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.	1 2 3 4 5 6 7	Operations Director agreed to re-assess resident (R1) and update the care plan and review all resident and staffing needs in order to ensure the residents needs are met. In addition, facility shall conduct staff training. Please submit a training log, and copy of the physician order for a Hoyer Lift.
	8 9 10 11 12 13 14	Based on record review and interviews conducted resident (R1) requires incontinence care and bathing assistance that was not provided as needed and in a timely manner. Resident requires two-person assist due to body size, but a a result of staff shortages reported during Summer 2020 assistance was not provided per care plan and as needed.	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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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