198603339-3-16-2023-28-AS-TVAO-CQZM8U-20230418092339

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603339
Report Date: 03/16/2023
Date Signed: 03/16/2023 02:15:56 PM

Substantiated

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
07/13/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20210713104812

FACILITY NAME:	PRIMECARE BELLFLOWER		FACILITY NUMBER:	198603339
ADMINISTRATOR:	KEERTHISINGHE, HIRANSHA S		FACILITY TYPE:	740
ADDRESS:	10245 TRABUCO STREET		TELEPHONE:	(562) 202-9669
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	6	CENSUS: 5	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Hiransha Keerthisinghe - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained a subdural hematoma while in care
Facility staff did not seek medical attention in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation(s). LPA Flores met with Jocelyn Moon Caregiver and explained the reason for the visit. Hiransha Keerthisinghe administrator arrived 15 minutes later.

The investigation consisted of the following: On 7/14/21 LPA Flores conducted a Health and Safety Check tour with facility's administrator Hiransha Keerthisinghe. In the kitchen, LPA observed sharp utensils were kept on drawer next to stove and cleaning supplies kept in cabinet under sink. Both have locks but do not lock properly. LPA Flores reviewed Resident # 1 (R1), Resident #2 (R2), Resident #3 (R3), Resident 4 (R4), and Resident #5 (R5) records. LPA also reviewed R1’s, R2’s, and R5’s medication. The following documents were requested from R1’s file: Physician report, admission agreement, and medication sheets. On 12/9/21 Investigator with Investigation Bureau (IB), Loraine Patterson conducted interview with administrator. On 5/20/22 a referral to the Department's clinical consult program was submitted.

(CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

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-20210713104812

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: PRIMECARE BELLFLOWER	FACILITY NUMBER: 198603339
	VISIT DATE: 03/16/2023

NARRATIVE

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The investigation revealed the following: Regarding allegation: Resident sustained a subdural hematoma while in care. It is alleged R1 was sitting in a wheelchair, being spoon fed dinner, and had a "very large hematoma" on the left side of R1's forehead. Per admission agreement, R1 was admitted to the facility on 6/26/21. Upon arrival administrator noted R1 was missing a medication. On 6/29/21 R1's responsible party was notified that R1 had "knocked head on the wall" over the phone around 9:00am. At around 5:30pm R1's responsible party arrived at the facility and took R1 to College Medical Center for medical care. R1 had a diagnosis of Dementia per physician's report dated 6/14/21. Medical records note that on 6/29/22 at 8:20pm, R1 was admitted to College Medical Center with chief complaint as suicidal ideation and unwitnessed abrasion to the forehead. A transfer from College Medical Center to St. Mary's Medical Center was arranged for R1 on 6/29/21 for higher level of care due to blunt head injury. R1 was admitted at St. Mary's Medical Center on 6/30/21 at 00:57am due to subdural hematoma. R1 went through two (2) procedures to assist with hematoma between 6/30/21 and 7/1/21. On 7/10/21 R1 was placed on hospice care due to R1's status. On 7/14/21 R1 passed away at the hospital. Death report revealed cause of the death was due to blunt head trauma. Administrator was interviewed and stated to have observed a "tiny redness approximately 1/2 inch on the left side of forehead." Per administrator R1 had restless behaviors for 3 days, such as lack of sleep and statements of wanting to "kill self".

Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.

Regarding allegation: Facility staff did not seek medical attention in a timely manner. It is alleged on the morning of 06/29/2021, the responsible party received a telephone call from the facility advising that the facility was going to call 911, but facility never called 911 and the resident was not transported to the hospital. On 6/29/21 at approximately 9:00am, R1's responsible party was notified that R1 had "knocked head on the wall". At approximately 5:30pm, R1's responsible party arrived at the facility and took R1 to College Medical Center for medical care. Medical records note that on 6/29/22 at 8:20pm R1 was admitted to College Medical Center with chief complaint as suicidal ideation and unwitnessed abrasion to the forehead. A transfer from College Medical Center to St. Mary's Medical Center was arrange for R1 on 6/29/21 for higher level of care due to blunt head injury.

(CONTINUED ON LIC 9099C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210713104812

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: PRIMECARE BELLFLOWER	FACILITY NUMBER: 198603339
	VISIT DATE: 03/16/2023

NARRATIVE

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R1 was admitted at St. Mary's Medical Center on 6/30/21 at 00:57am due to subdural hematoma. On 7/10/21, R1 was placed on hospice. On 7/14/21; R1 passed away at the hospital. Death report revealed cause of the death was due to blunt head trauma. Interview with administrator revealed, administrator contacted R1's responsible party in the morning and upon responsible party arriving they requested they will drive R1 to the hospital and administrator "should have called 911" instead.

Based on interviews and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustained a subdural hematoma while in care. Refer to LIC 421IM***

The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49(e) - (f); if the department determines the death of the client is due to neglect.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20210713104812

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: PRIMECARE BELLFLOWER	FACILITY NUMBER: 198603339
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/17/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities shall...:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator and licensee will obtain training from an outside source in procedures to ensure the safety of the resident and emergency situations, contacting 911,and will provide training to staff regarding injuries and contacting 911. Administrator will schedule training by POC due date 3/17/23 and submit training to the dept. by 3/23/23.
	8 9 10 11 12 13 14	Based on documents review, and interviews Licensee failed to ensure R1 did not sustained a subdural hematoma to the head which poses an immediate health, safety, or personal rights risk to the persons in care.	8 9 10 11 12 13 14
Type A 03/17/2023 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator and licensee will obtain training from an outside source in procedures to ensure the safety of the resident and emergency situations, contacting 911,and will provide training to staff regarding injuries and contacting 911. Administrator will schedule training by POC due date 3/17/23 and submit training to the dept. by 3/23/23.
	8 9 10 11 12 13 14	Based on documents review, and interviews conducted Licensee failed to contact 911 in a timely manner which poses an immediate health, safety, or personal rights risk to the persons in care.	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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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