198603161-6-22-2021-28-AS-MVAO-C5BQL2-20210727121512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603161
Report Date: 06/22/2021
Date Signed: 06/22/2021 04:00:02 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
01/05/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210105160055

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: 44	DATE:	06/22/2021
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Haigaz Kazazian, Business Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident had access to cleaning supplies while in care resulting in hospitalization.

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 Business Director Haigaz Kazazian.

The investigation consisted of the following: On 1/13/2021 due to the COVID-19 pandemic a telephonic visit was conducted. Staff (S1) was interviewed. The Wellness Director/Coordinators and memory care caregivers were not available for interviews. A virtual physical plant tour of Memory Care Unit was conducted at 1:05 PM via FaceTime. No memory care residents were interviewed. On 5/14/2021 a physical plant inspection of the Memory Care unit, assisted living floors, medication room, and common areas was conducted. Staff (S2- S4) were interviewed. The following documents were obtained: Identification and Emergency Information/Face Sheet, Physician Report, Resident Appraisal, Appraisal/Needs and Services Plan, hospital discharge documents, incident report, staff contact information, LIC 500, resident roster, and memory care protocols/training log.

See LIC 9099C for report continuation

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: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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-20210105160055

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: 06/22/2021

NARRATIVE

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Allegation: "Resident had access to cleaning supplies while in care resulting in hospitalization." Based on record review and interviews conducted the findings revealed that on 12/19/2020 at approximately 11:45 PM Dementia resident (R1) found a 16 ounce hand sanitizer bottle and drank it. The resident resided in the Memory Care unit of the facility. At that time the facility had a COVID-19 outbreak that required infection control supply carts in COVID-19 areas that were equipped with personal protective equipment (PPE). The hand sanitizer was inside the drawer of the isolation cart that did not have a lock. One staff witnessed the incident and called 911 emergency. The resident was transported to Greater El Monte Community Hospital and treated for accidental ingestion. Items that could constitute a danger must be stored inaccessible to Dementia residents. Staff interviews confirmed the incident. Per staff interviews, there were staff shortages at the time of the incident due to the COVID-19 outbreak at the facility. Staff were working 12-hour shifts in the Memory Care Unit.

Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC 9099D.

An exit interview was conducted and Plans of Correction were reviewed and developed with Business Director. A copy of the report and appeal rights were discussed and left with Business Director Haigaz Kazazian.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210105160055

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: 06/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/23/2021 Section Cited CCR 87705(f)(1)	1 2 3 4 5 6 7	87705(f)(1). Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met by evidence of:	1 2 3 4 5 6 7	Facility agreed to submit a written plan of correction that addresses hand sanitizer use in the Memory Care Unit. Submit by POC due date.
	8 9 10 11 12 13 14	Based on records review and interviews conducted on 12/19/2020 the facility failed to store hand sanitizer in a locked PPE cart and resident (R1) drank the hand sanitizer bottle. Items that could constitue a danger to Dementia residents must be inaccessible. This poses an immediate healthy & safety risk.	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: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC9099 (FAS) - (06/04)

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