198603383-2-13-2024-28-AS-RORN-D4UUWX-20240501155727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603383
Report Date: 02/13/2024
Date Signed: 02/13/2024 03:09:30 PM

Unsubstantiated

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
07/14/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220714141442

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:	02/13/2024
		UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Robert Jakini – Executive Director		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff did not follow COVID protocol.
Staff did not aid residents with incontinence needs.
Staff did not observe change in residents condition.
Staff did not feed bedridden residents
Staff did not aid residents with hygiene needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted a subsequent complaint investigation visit regarding the above mentioned allegations. LPA met with Robert Jakini (Executive Director) and explained the reason for the visit.

Investigation consisted of the following: On 07/18/2022, LPA requested copies of Emergency and Identification Information, Most current Physician report, Admission Agreement, Most current Needs and Services Plan, Most current incident reports, Hospice notes or Home Health Notes, Case Notes, Death Report for Resident 1 - Resident 6 (R1 - R6). LPA conducted a tour of facility and common areas. LPA observed a sufficient supply of perishable and non-perishable foods and observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. During today's visit, LPA interviewed Executive Director, Staff 1 - 4 (S1 - S4), and Resident 7 - Resident 15 (R7 - R15). LPA also obtained a copy of the shower schedule.
(Continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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-20220714141442

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: 02/13/2024

NARRATIVE

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The investigation revealed the following:

Regarding the allegation "staff did not follow COVID protocol”, it is alleged that staff failed to follow COVID-19 guidelines. Staff interviewed denied the allegation and stated that full PPE supplies were used when there was a COVID-19 positive case. Residents interviewed could not corroborate the allegation.

Regarding the allegation "staff did not aid residents with incontinence needs”, it is alleged that staff were not changing the diaper for R1, R4, and R5. Staff interviewed denied the allegation. They stated all residents that need diaper change receive incontinence assistance every 2 hours or as needed. Even if the resident has COVID-19 the staff are expected to wear full PPE supplies and provide the incontinence assistance. Residents interviewed could not corroborate the allegation.

Regarding the allegation "staff did not observe change in residents condition”, it is alleged that staff did not check on R1 for 6-7 hours. Staff interviewed denied the allegation. They stated that R1 was severely ill and was placed on "alert charting" which meant that staff had to check on R1 every hour and complete a chart behind the resident's bedroom door. Residents interviewed could not corroborate the allegation.

Regarding the allegation "staff did not feed bedridden residents”, it is alleged that staff did not feed R1 and R2 because R1 had COVID-19 and staff did not want to get near R1 and R2 would eat slow so the staff would get impatient. Staff interviewed denied the allegation. They stated that all residents are provided food and assisted with eating if the resident needs assistance. If a resident has COVID-19 then the staff are expected to wear full PPE supplies and assist the residents with feeding. Residents interviewed could not corroborate the allegation.

Regarding the allegation "staff did not aid residents with hygiene needs”, it is alleged that staff did not shower R4. Staff interviewed denied the allegation. They stated all residents receive shower assistance up to 2-3 times a week or as needed. LPA reviewed the shower schedule and observed all residents name listed 2-3 times throughout the week. Residents interviewed could not corroborate the allegation.

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.

Exit interview held and a copy of the report was provided

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC9099 (FAS) - (06/04)

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