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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603161
Report Date: 03/17/2023
Date Signed: 03/17/2023 12:30:25 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
11/30/2020 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201130165142
FACILITY NAME:CALIFORNIA MISSION INNFACILITY NUMBER:
198603161
ADMINISTRATOR:LOPEZ, GINAFACILITY TYPE:
740
ADDRESS:8417 MISSION DRTELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:85CENSUS: 34DATE:
03/17/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dwight Dunagan, Executive DirectorTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Staff neglect resulting in resident developing a pressure injury while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent visit to deliver findings on the investigation conducted by DSS Investigation Branch Investigator Philipe Miles. LPA met with Wellness Director Ruby Magao and explained the purpose of the visit. Executive Director was unavailable.

The investigation consisted of the following: On 12/2/2020, an initial visit was conducted with Administrator Laura "Lori" Waters. Due to the COVID-19 pandemic the visit was conducted telephonically. Resident (R1's) file documents were requested, but not obtained due to staffing shortages. On a later date, Ms. Waters provided copies of requested documents [ID/Emergency Information/Face Sheet, Preplacement Appraisal, Resident Appraisals, Appraisal Needs and Services Plan, Physician's Report, Admission Agreement, Hospice/Palliative Care Plan, unusual incident reports (Sep 2020- Dec. 2020), caregiver notes (months- Sep. 2020- Dec. 2020), authorized representative form, resident roster, and LIC 500 Personnel Report.] Investigator Miles obtained obtained hospital, medical, and Palliative Care records.
See LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
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 4
Control Number 28-AS-20201130165142
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: 03/17/2023
NARRATIVE
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Allegation: Staff neglect resulting in resident developing a pressure injury while in care. The finding of this allegation has been determined by evidence in the investigation report of Investigator Philippe Miles. The investigation report includes: Resident (R1's) hospital medical records, Palliative Care records, Wound Physician records, Physician Report, Plan of Care, resident appraisals, and photographs. Resident (R1) was admitted to the facility on 9/29/2020. Per Preplacement Appraisal completed on 10/02/2020, resident was alert and oriented, non-ambulatory, used a wheelchair and required help in all activities of daily living (ADLs). Palliative care by Corinthian Hospice was initiated on 10/05/2020. The assessment revealed that R1 had Stage 1 on both groin areas, left and right stomach folds, and Stage 2 sacral area; nurse visits were scheduled 1-2x/week. Facility staff admitted they provided wound care prior to Hospice/Palliative Care start. When the resident was admitted to the facility there were open wounds on thighs, and rashes under belly that emitted a foul smell. On 10/15/2020, Palliative Care nurse notes state a Stage 3 to sacral coccyx area was observed. Facility staff were educated by nurse on repositioning, skin integrity, ad preventing skin breakdown.

On 11/23/2020, resident (R1) was transferred to Methodist Hospital of Southern California and was diagnosed with septic shock, acute kidney injury, and aspiration pneumonia. On 11/25/2020, the resident was transferred to Kaiser Permanente Hospital with the following active diagnoses: septic shock, pressure ulcer of coccyx, Sacral Deep Tissue Pressure Injury (DTPI) previously a Stage 3, with open linear sore; Measurements 3 x 0.5 cm, new Right ankle DTPI; Measurements: 0.5 x 0.5 cm, Stage 4 Midback open wound; Measurements: 3 x 3 x 2.5 cm, and aspiration pneumonia. On 11/27/2020, the resident was discharged back to the facility with a Foley catheter. On 11/30/2020, R1 was readmitted to Corinthian Hospice for Palliative Care. On 1/7/2021, resident (R1) developed a new stage III pressure wound on the coccygeal area. On 10/23/2021, R1 was transferred to Country Villa Health Care Center Long Beach per MD order due to unresolved skin rashes to bilateral upper thighs. On 12/14/2021, R1 was discharged from California Mission Inn. After hospitalization the resident was transferred to a different board and care facility. The resident died on 5/13/2022. There is sufficient evidence to corroborate the allegation. The resident developed pressure injuries while under the care of the facility, and was admitted to the hospital with deep Stage 4 pressure wounds.

Per evidence review presented in the Investigation Case Report, medical records, and interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099D. **The licensee was informed that a civil penalty might be assessed based on Health and Safety Code.

Exit interview was conducted with Wellness Director Ruby Magao. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20201130165142
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: 03/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2023
Section Cited
CCR
87615(a)(1)
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Prohibited Health Conditions. 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: Stage 3 and 4 pressure injuries. This requirement was not met evidenced by:
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Licensee/Administrator agrees to conduct staff training on regulation 87615, resident Care Plans, and Specialized Care Plans.

Submit by tomorrow a written statement of how this deficiency will be corrected. In addition, submit proof of staff training; which includes staff signatures by 3/22/2023.
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Based on record review, the licensee did not comply with the section cited above in that staff did not follow Plan of Care, were doing wound care, and retained the resident with a Stage 3 pressure injury; which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
03/21/2023
Section Cited
CCR
87466
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Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.....the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Licensee/Administrator agress to conduct staff training on regulation 87466, and staff communication protocols regarding changes in residents conditions.
Submit by tomorrow a written plan of how the deficiency will be corrected. Submit proof that staff were trained by 3/22/2023.
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This requirement has not been met as evidenced by: Based on medical record review and investigation report, staff failed to provide routine and MD order repositioning of R1 to prevent to prevent the advancement of pressure injuries. This poses an immediate a health and safety risk to the residents in care.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20201130165142
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: 03/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2023
Section Cited
CCR
87411(d)(3)
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Personnel Requirements - General. All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following....(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
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Administrator agrees to conduct staff training on incontinence care, care and supervision, and adherence to facility Plan of Operation protocol procedures; which may include hiring additional staff. Submit proof of correction to CCLD by POC due date.
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This requirement was not met evidenced by: Based on investigation report, medical records, and interviews conducted staff failed to do reposition/rotation care as needed, and resident had to call front desk staff to reposition and assist with incontinence care; which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4