198603383-4-23-2024-28-AS-RORN-D4UUWW-20240501155726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603383
Report Date: 04/23/2024
Date Signed: 04/23/2024 03:55:00 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: 36	DATE:	04/23/2024
		UNANNOUNCED	TIME BEGAN:	08:03 AM
MET WITH:	Robert Jakini (Executive Director)		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Questionable deaths
Residents had severe UTI.
Staff did not seek medical attention for residents.
Staff did not follow prescribed meals for residents.
Staff did not report incidents to CCL.
Staff did not document residents falls.

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. On 02/13/2024, 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. During today's visit, LPA interviewed Executive Director, Staff 1, Staff 2, Staff 4 (S1, S2, S4), and Resident 16 - Resident 18 (R16 - R18). (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: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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: 04/23/2024

NARRATIVE

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The investigation revealed the following:

Regarding the allegation "questionable deaths”, it is alleged that Resident 1 (R1) - Resident 6 (R6) did not seem to be ill and upon developing a medical diagnose they passed away within days. Complainant is not aware if any of the residents had any underlining conditions. Staff interviewed stated these residents had underlying conditions and were placed on hospice, and that their death were not due to neglect. Review of records all residents were on hospice. LPA obtained copies of death certificates for all residents. R1 (80 years old) passed away on 06/12/2022: immediate cause of death was cardiopulmonary arrest, and the underlying causes were acute respiratory failure and Covid-19. R2 (86 years old) passed away on 06/06/2022: immediate cause of death was Alzheimer’s Disease. During the investigation, LPA could not determine the true name of R3. Staff stated there has been no resident with that name or a resident that matches the details provided by the complainant. R4 (84 years old) passed away on 12/05/2021: immediate cause of death was cardiopulmonary arrest, and the underlying cause was senile dementia. R5 (82 years old) passed away on 03/17/2022: immediate cause of death was cardiopulmonary arrest, and the underlying cause were urosepsis and atherosclerosis of coronary artery. R6 (83 years old) passed away on 12/18/2021: immediate cause of death was cardiac arrest, and the underlying cause were respiratory failure and Parkinson’s disease. Residents interviewed did not express that they are being neglected.

Regarding the allegation "residents had severe UTI”, it is alleged that R4, R5 and R6 had UTI. Staff interviewed stated that residents do get UTI, but it is not due to neglect. They stated all residents that need diaper change receive incontinence assistance every 2 hours or as needed and staff are trained to properly cleaned the residents to avoid UTI. Residents interviewed did not express that they are being neglected.

Regarding the allegation "staff did not seek medical attention for residents”, it is alleged that R3's tube (unsure type of tube) that was attached to R3's stomach looked infected. Complainant did not provide a last name for R3. During the investigation, LPA could not determine the true name of R3. Staff stated there has been no resident with that name or a resident that matches the details provided by the complainant. Residents interviewed could not corroborate the allegation.

(Continued to LIC 9099-C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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: 04/23/2024

NARRATIVE

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Regarding the allegation "staff did not follow prescribed meals for residents”, it is alleged that R3 was on mechanical soft food diet, but staff kept feeding R3 regular food. Complainant did not provide a last name for R3. During the investigation, LPA could not determine the true name of R3. Staff stated there has been no resident with that name or a resident that matches the details provided by the complainant. Staff interviewed denied the allegation stated that they follow a list that is on the kitchen that has all the residents with modified/prescribed diets. Residents interviewed could not corroborate the allegation. LPA observed the list for modified/prescribed diets in the kitchen.

Regarding the allegation "staff did not report incidents to CCL” and "staff did not document residents falls", it is alleged that a resident had a fall and it was not documented or reported to Community Care Licensing (CCL). There is no records of this resident having a fall and staff could not remember if this resident had a fall either. Staff stated that the procedure regarding falls is as follows: contact the med-techs to come and assess the resident, write a report and submit it to supervisor. S1 is in charge of completing the licensing incident report and submitting it to the Executive Director for signature and the Executive Director submits it to CCL.

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: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC9099 (FAS) - (06/04)

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