198603383-6-15-2024-28-AS-TVAO-D6CUMD-20240618154206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603383
Report Date: 06/14/2024
Date Signed: 06/15/2024 01:52:58 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
08/18/2022 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220818172814

FACILITY NAME:	TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE		FACILITY NUMBER:	198603383
ADMINISTRATOR:	HIGGINS, DEBORAH		FACILITY TYPE:	740
ADDRESS:	1155 VIA VERDE		TELEPHONE:	(503) 443-1818
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	60	CENSUS: 35	DATE:	06/14/2024
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Robert Jakini - Executive Director		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility did not notify appropriate doctor of resident's change in condition.

INVESTIGATION FINDINGS:

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*This report is a corrected version for report dated 6/11/24 to correct missing census and executive director's last name.* Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint visit regarding the above allegation. LPA met with Robert Jakini and explained the reason for the visit.

The investigation consisted of the following: On 8/22/22, LPA Galarza and Ramirez conducted a health and safety check visit at the facility, no concerns were observed. Interviews with 2 staff were conducted and copies of incident report and other documents were obtained. On 8/23/22, LPA Galarza interviewed Resident #1’(R1’s) representative and Skilled Nursing Facility over the phone. On 8/25/22, Investigation Bureau of the department accepted assignment to request medical records for R1. On 2/26/24, LPA Flores was re-assigned complaint investigation. On 3/8/24, LPA Flores requested additional records from the facility. On 3/13/24, LPA Flores subpoenaed medical records for hospitalization and skilled nursing facility. On 5/24/24, LPA Flores interviewed 6 staff over the phone. (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: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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 7

Control Number 28-AS-20220818172814

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: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE	FACILITY NUMBER: 198603383
	VISIT DATE: 06/14/2024

NARRATIVE

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On 6/3/24, LPA Flores contacted Guardian Pharmacy. On 6/11/24 LPA Flores delivered findings for complaint.

The investigation revealed the following: Regarding allegation: Facility did not notify appropriate doctor of resident’s change in condition. It is alleged incorrect doctor was notified of resident’s change in condition. Record review revealed that upon R1’s return to the facility on 6/3/22 family representative notified facility of change of physician. The change was noted in the facility’s face sheet under resident’s contacts – medical, previous physician was crossed out and new physician was written in ink with contact phone number. On 6/7/22 facility staff notified a different physician of change in condition per records reviewed. The physician notified was not previous or R1’s current physician. Per interviews conducted with staff, physician notified is not under the same medical group as R1’s physician at the time. Staff also stated that any changes are noted in the hard copy file as well as the facility’s digital database. The facility staff that notified the physician does not recall the incident. However, per records reviewed the staff made a mistake and notified the wrong physician. Notes revealed physician who was notified, then contacted the correct physician of R1’s change in condition.

Based on LPAs interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Robert Jakini and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 7

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
08/18/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220818172814

FACILITY NAME:	TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE		FACILITY NUMBER:	198603383
ADMINISTRATOR:	HIGGINS, DEBORAH		FACILITY TYPE:	740
ADDRESS:	1155 VIA VERDE		TELEPHONE:	(503) 443-1818
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	60	CENSUS: 35	DATE:	06/14/2024
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Robert Jakini - Executive Director		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Resident suffered a fracture while in care.
Staff did not notice a change in resident's condition.
Resident developed a wound while in care.
Facility did not administer medications to resident.
Facility did not ensure resident's medications were ordered.
Facility did not ensure resident received Home Health Care.

INVESTIGATION FINDINGS:

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Unsubstantiated

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: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 28-AS-20220818172814

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: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE	FACILITY NUMBER: 198603383
	VISIT DATE: 06/14/2024

NARRATIVE

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On 6/3/24, LPA Flores contacted Guardian Pharmacy. On 6/11/24 LPA Flores delivered findings for complaint.

The investigation revealed the following: Regarding allegation: Resident suffered a fracture while in care due to lack of supervision. It is alleged that on 4/11/22, while under the care of the facility R1 fell, was transported to the hospital where R1 was diagnosed with a hip fracture. Documents reviewed revealed the following: R1 was admitted to the facility on 3/25/22. Preplacement Appraisal Information dated 3/20/22 notes R1 requires checks due to not being able to balance. There is no previous history of falls recorded on preplacement appraisal or needs and care plan. Per physician’s report dated 8/4/21, R1 does not have any motor impairment or history of falls. Per incident report dated 4/16/22, on 4/11/22 R1 had an unwitnessed fall in R1’s room at around 6:45pm. Facility staff contacted 911 “immediately” and notified R1’s representative and physician. Medical Records revealed R1 was hospitalized on 4/11/22 due to a mechanical fall which resulted in a left proximal femur fracture. Per interviews with staff, R1 was last seen in the dining room around 5:00pm and went back to the room. Staff conducts checks on residents at least every 2 hours or based on each individual needs. R1 was heard screaming and therefore a staff that was walking by heard R1 and responded to R1. Although, R1 did sustain a fracture during the fall, there is insufficient evidence that R1 required assistance due to a history of falls or that there was no staff to provide assistance.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff did not notice a change in resident's condition. It is alleged during the 4 days from June 3rd to June 7th R1’s condition deteriorated with a weight loss of 12 lbs. Records reviewed revealed R1 was hospitalized on 4/11/22 due to a fracture. On 4/18/22, R1 was discharged to a skilled nursing facility. On 4/28/22, R1 was hospitalized due to severe anemia. On 4/19/22, Skilled nursing noted R1’s weight as 156 lbs. On 5/18/22, skilled nursing noted abnormal weight loss for R1. On 5/20/22, skilled nursing noted R1 had lost 10 lbs. On 5/31/22, R1’s weight was noted as 152 lbs. R1 was discharged from skilled nursing to residential facility by physician on 5/31/22, “The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility”. On 6/2/22, Physician ordered to discharge R1 to residential facility. On 6/3/22, R1 was re-admitted to residential facility. On 6/4/22, facility staff noted R1 refused a meal. On 6/5/22, facility staff noted R1 has a decrease of appetite and noted that Health Residential Services (HRS) staff will continue to monitor R1. On 6/6/22, facility staff noted that R1 had refused meals. (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: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 28-AS-20220818172814

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: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE	FACILITY NUMBER: 198603383
	VISIT DATE: 06/14/2024

NARRATIVE

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On 6/7/22, physician and R1’s representative was notified of R1’s change in condition. R1’s physician visited R1 and by 4:30pm R1 was transferred back to Skilled Nursing Facility per physician’s request. On 6/8/22 it was noted by Skilled Nursing staff that R1 was weighing 140 lbs. Although R1 did lose 12 lbs. between 5/31/22 and 6/8/22, R1 had a history of abnormal weight loss. Weight loss began in SNF and was noted as abnormal weight loss during the stay at the SNF. In addition, R1 had a history of anemia. Per records review facility staff encouraged R1 to eat meals between 6/3/22 and 6/6/22. However, R1 refused meals on 6/6/22 and facility staff notified physician within 24 hours of R1 refusing meals. Interviews with staff revealed that when residents refused a meal staff notifies HRS to monitor and once a resident continues to refuse all three meals staff notifies physician. Facility staff followed the facility’s procedures for the change in condition.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Resident developed a wound while in care. It is alleged R1’s surgical wound re-opened, new wound on lower back, and a hematoma on heel of left foot was discovered once arrived at SNF. On 4/11/22, R1 was hospitalized due to hip fracture and required surgery. On 4/27/22, Advantage Wound Care was in place for R1, who provided care for wound on left hip and thigh upper area for surgical wounds. On 6/1/22, Advantage Surgical Wound Care visited R1 and managed wounds in multiple locations which were not described in records reviewed. On 6/3/22, facility noted that R1 is receiving wound care for a stage 2 wound upon readmission. The location of the wound was not identified. On 6/7/22, R1 was readmitted to SNF. On 6/8/22, SNF staff noted the following regarding R1’s skin. R1 had “multiple sites of skin discoloration; left hip surgical wound, sacrum pressure Deep Tissue Injury (DTI), right 1st toe trauma, and left heel DTI”. Physician noted care for R1 to monitor left heel for signs of infection, monitor surgical hip for signs of infection, monitor right toe, and order heel protectors to prevent from opening. On 6/15/22, Advantage Surgical and Wound care notes the following four wounds “(1) pressure left heel DTI no drainage, (2) surgical left hip wound was resolved, (3) pressure sacral coccyx DTI debris, surgical, and (4) trauma to right 1st toe no drainage and monitor”. On 6/15/22, pressure sacral coccyx developed into a stage 3 wound. Based on documents reviewed, R1 had two surgical wounds when admitted at SNF on 4/18/22 for which R1 was receiving care. On 6/1/22, R1 continued to receive care for surgical wound. On 6/3/22, facility noted the surgical wounds. On 6/8/22, R1 had three sites of deep tissue 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: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 28-AS-20220818172814

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: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE	FACILITY NUMBER: 198603383
	VISIT DATE: 06/14/2024

NARRATIVE

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However, the sites were not staged. The sacral coccyx wound got first stage on 6/15/22 while R1 was at the skill nursing. Therefore, there is not enough evidence to say that R1’s wounds developed while in care at the facility. Deep Tissue Injuries(DTI) can develop as soon as within 24 hours due to friction while moving or transferring a resident. R1 returned to skill nursing on 6/8/22 and did not return to the facility. Therefore, it cannot be determined that DTIs were caused by a lack of care of facility staff.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegations: Facility did not administer medications to resident and Facility did not ensure resident's medications were ordered. It is alleged R1’s responsible party provided physical list of updated medications to facility’s management staff (Staff #2 S2) and the listed medications were not ordered or administered to R1. Document review revealed the following, on 6/3/22, R1 returned to residential facility after being discharged from SNF. Facility’s medication sheet for June 2022 lists a total of 21 medications, of which 9 were started on 6/7/22. On 6/3/22, SNF medication listed 17 medications at the time of discharge. The additional medications observed were vitamins and an antibiotic. Interviews conducted with facility staff revealed facility works with a pharmacy which provides the profile and dispenses the medication. Once the entry of the medication list is inputted the medication is then ordered and delivered to the facility. Delays of medication are usually caused by medication error or new orders that need to be verified with the physician. Per staff, R1 came with some medication which was noted in the medication sheet. Interview with pharmacy representative revealed that although R1 used their profile system to list the medication sheet, R1 did not use their pharmacy to dispense R1’s medication. There was a delay of providing 9 of the medications. However, it is uncertain if the reason for the delay of medication dispensed to R1 between 6/4/22 – 6/6/22 was due to the pharmacy used by R1 not providing refills, physician needed to clarify the medication, or if the facility failed to request the medication.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Regarding allegation: Facility did not ensure resident received Home Health Care. It is alleged no Home Health Care was ordered for R1 by the facility. On 5/31/22, Physician’s discharge notice notes, “The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility” (Skill Nursing Facility). (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: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 28-AS-20220818172814

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: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE	FACILITY NUMBER: 198603383
	VISIT DATE: 06/14/2024

NARRATIVE

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On 6/2/22, Physician’s order notes to discharge R1 to the Terraces with the following note, “may have home health, OT, RN for evaluation”. Interviews conducted with facility’s staff revealed that usually when a resident is discharged from a SNF the resident is discharged with home health care if needed. If the resident needs to have home health care while at the facility, usually the family will contact and place home health due to financial decisions, or in some instances the facility will assist. In R1’s case due to the timeframe of the change in condition of R1, it was uncertain whether there was a need for home health and/or if home health had been requested for R1 by SNF. Per the physician’s statement upon discharge of R1 “may” have home health but it was not determined R1 needed to have home health upon discharge.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Robert Jakini and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC9099 (FAS) - (06/04)

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