198603208-10-4-2023-28-AS-FFIS-CWR6GQ-20231018204820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603208
Report Date: 10/04/2023
Date Signed: 10/04/2023 04:40:21 PM

Unsubstantiated

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
10/22/2021 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211022110119

FACILITY NAME:	LOVING ARMS RESIDENTIAL CARE FOR SENIORS III		FACILITY NUMBER:	198603208
ADMINISTRATOR:	BISNAR, LOURDES		FACILITY TYPE:	740
ADDRESS:	11507 THOMAS PLACE		TELEPHONE:	(562) 864-6308
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 0	DATE:	10/04/2023
		UNANNOUNCED	TIME BEGAN:	03:35 PM
MET WITH:			TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Resident has multiple pressure injuries.
Resident has a stage 4 pressure injury.

INVESTIGATION FINDINGS:

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On 10/22/21 Licensing Program Anaylst (LPA) Nicol Wesley, conducted the initial complaint visit, LPA conducted a health and safety visit. LPA Wesley requested a copy of: staff roster, resident roster, and the following documents for resident #1 (R1) to be faxed/emailed by 10/25/21: Admission agreement, Emergency Identification page(ID Page), current Physicians report, Appraisal needs and services plan, Palliative care plan, and Hospice care plan. During the intial day of visit, LPA Wesley and Administrator Lourdis Bisnar completed an entire tour of the physical plant. LPA Wesley did not observe any immediate health and safety concerns.

Continuation on 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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-20211022110119

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: LOVING ARMS RESIDENTIAL CARE FOR SENIORS III	FACILITY NUMBER: 198603208
	VISIT DATE: 10/04/2023

NARRATIVE

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LPA Calderon reviewed R1's Hospice Plan of Care. Review of the Hospice Care Plan indicated: On 10/01/21, R1 was noted to have left heel (stage 3) wound, shoulder wound (stage 2) and a stage 4 wound right and left buttock, which were addressed in the Hospice Care Plan. R1’s Hospice Care Plan indicated monitoring of wounds, treatment, provide low air mattress, instruct staff on prevention techniques, educate on repositioning / turning patient.

Based on LPA Calderon interview with R1’s Hospice Agency: WGM Consulting LLC, Case Manager for R1 reported R1 initial hospice admission was on 09/05/21 and hospice agency was treating R1 for wounds. On 10/01/21 R1 was re-admitted to Hospice after hospital discharge to continue wound care. During R1 hospitalization, hospice agency discharged R1 and re-admitted R1 once R1 returned to the facility, which is the Hospice Agency policy. R1 Case Manager informed LPA that the Hospice Agency staff was unable to confirm if facility staff neglected R1 wounds and confirmed that the facility would report any changes for R1 to the Hospice Agency. Case Manager confirmed R1 was being treated for wounds by Hospice agency Nurses.

On 09/22/23, LPA interviewed Administrator who stated R1 was not neglected at the facility-by-facility staff. Administrator stated R1 was admitted to the licensed facility with wounds on 5/1/21.

LPA made several attempts to contact R1 family and Home Health, however, attempts were unsuccessful.

The investigation revealed that there was insufficient information to support the above-mentioned allegations and although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were noted per Title 22 Division 6 Chapter 8.

LOVING ARMS RESIDENTIAL CARE FOR SENIORS III was closed on 02/06/2023, therefore a copy of the LIC 9099 report dated 09/22/23 was mailed to the Licensee's mailing address via certified mail on 10/4/23.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC9099 (FAS) - (06/04)

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