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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603384
Report Date: 02/03/2022
Date Signed: 02/03/2022 05:29:42 PM

Substantiated


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
01/11/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220111111836
FACILITY NAME:PASADENA HIGHLANDSFACILITY NUMBER:
198603384
ADMINISTRATOR:CANO, KAYFACILITY TYPE:
740
ADDRESS:1575 E WASHINGTON BLVDTELEPHONE:
(801) 815-0808
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:245CENSUS: 154DATE:
02/03/2022
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Brodey DeBorde, Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident fell while in care resulting in injury.
Not enough staff to meet residents needs.
Resident's Care Plan not being adhered to.
Food services are inadequate.
Medications are not being administered according to physician's instructions.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations.The purpose of the visit was discussed with Executive Director Brodey DeBorde.


The investigation consisted of: On 1/19/22 LPA toured the interior facility grounds. No health and safety issues were observed during the visit. Staff (S1-S5), resident (R1), and family (F1) were interviewed. Video surveillance of the fall incident dated 10/20/21 was reviewed with Executive Director. Resident (R1's) documents [Face Sheet, Physician Orders, Preplacement Appraisal Information, Resident Assessment, Physician Reports, Admission Agreement/Resident Ledger, Hospice Plan of Care, Progress Notes, Health and Services Evaluation/Appraisal Needs and Services Plans, resident roster, staff roster, Medication Administration Report (Nov. 2021- Jan. 2022), and incident report dated 10/20/21 were obtained. Facility Plan of Operation was reviewed. On 2/3/2022, staff (S6) was interviewed.

See LIC9099C for report continuation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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 5
Control Number 28-AS-20220111111836
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: PASADENA HIGHLANDS
FACILITY NUMBER: 198603384
VISIT DATE: 02/03/2022
NARRATIVE
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Allegation: "Resident fell while in care resulting in injury." Based on record review and interviews conducted the findings indicate that on 10/20/2021 resident (R1) lost it's balance and fell in the lobby by the elevator, which resulted in a brain injury [traumatic subarachnoid hemorrhage].The fall was not witnessed, but two staff responded immediately and called 911 Emergency. Video surveillance footage confirmed the resident was walking without assistance and fell backwards. LPA attempted to interview R1, but the resident was not oriented to time/place, had no recollection of a fall, nor was able to press the pendant when instructed. Resident has cognitive impairment that makes it unlikely for the resident to be able to press the emergency response pendant for assistance. Per staff interviews, R1 has a private duty attendant (caregiver) that often assists facility staff with escorting resident to meals. Per plan of operation, private caregivers are "permitted to provide services to residents in their units." All staff interviews revealed that it was an unwritten understanding that the private caregiver would escort R1 to the dining room or activities if present at the facility. However, if a resident has a private caregiver it does not relieve the facility of responsibility.

Allegation: "Not enough staff to meet residents needs." Upon hospital discharge resident (R1) returned to the facility and required total care that included repositioning and feeding assistance. Facility protocol is that caregivers shall rotate/reposition resident every 2-3 hours. Per family observation the resident was not repositioned as required by physician order on multiple occasions. Facility staff was notified by R1's family that the resident's rotation/repositioning was not being performed as required. Incontinence care was not provided as needed. Staff interviews confirmed that the first 2 weeks after the resident returned to the facility rotation/repositioning assignments were missed by caregivers, and that at that time the facility was experiencing staffing shortages that contributed to missed elements of care. Executive Director stated that from October 2021- to present the facility has been short staffed 3-4 caregivers, but has been utilizing registry agency staff. All staff interviews confirmed staff shortages were the reason resident (R1's) needs were not met. During the holidays the facility had major staffing shortages.

Allegation: "Resident's Care Plan not being adhered to." Based on record review and interviews conducted the finding revealed that resident (R1's) Care Plan was not followed. Resident (R1's) Care Plan requires escort assistance. Per staff interviews, the resident was on "minimal assistance", but the family was being charged for escorting assistance prior to the fall. Staff acknowledged that escorting assistance was provided, just not all the time. The Plan of Operation states: "At minimum, the staff at Pasadena Highlands will perform an annual assessment of your needs, or more frequent assessment if your condition warrants, or regulations mandate." Per R1's document review it was observed that the resident was not assessed in 2018. The Physician Reports on file were dated 8/24/2016 and 11/2/2021. Staff acknowledged that between years 2016 - 2021 there were changes in condition, but updated Physician Reports were not obtained.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 28-AS-20220111111836
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: PASADENA HIGHLANDS
FACILITY NUMBER: 198603384
VISIT DATE: 02/03/2022
NARRATIVE
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Allegation: "Food services are inadequate." During October 2021 - November 2021 resident (R1) was not receiving dinner meals or fed in a timely manner. It is alleged that most of the feeding issues occurred during the evening shift because R1's private caregiver is not at the facility at that time. Staff are provided mealtime feeding schedules, which include a window of feeding times. Staff interviews revealed that caregivers are to first assist with transporting residents to the dining room, and then feed residents that require assistance in their rooms. Resident (R1) did receive meals, but the meals were either received late, or staff did not feed the resident until much later. Staff acknowledged that R1 was not fed in a timely manner due to staff shortages. Staff also notified R1's family they were short staffed.

Allegation: "Medications are not being administered according to physician's instructions." On January 1, 2022 the facility was short staffed, and staff (S6) informed resident (R1's) family that the evening medications had been administered. However, R1's family member was in the resident's unit all day and did not observe med-tech administer the evening medications. Staff (S6) confirmed that the medications had not been administered. Additionally, resident (R1) physician order indicated crush medications, but staff (S6) provided the resident the medication without being crushed. The med-tech also took the wrong inhaler to R1's room, but it was not administered because family member noted it was the wrong inhaler. Staff later returned with the correct inhaler medication. All staff interviews confirmed that on January 1, 2022 resident (R1's) medications were not administered according to physician order.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22.

Exit interview was conducted with Executive Director Brodey DeBorde. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220111111836
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: PASADENA HIGHLANDS
FACILITY NUMBER: 198603384
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
02/17/2022
Section Cited
CCR
87464(f)(4)
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Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.
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Facility shall evaluate staffing needs, re-assess resident (R1), update the Care Plan, and submit a written statement and proof of staff training.

In addition, facility shall review all resident records to ensure Care Plans have been updated.
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Based on record review and interviews conducted resident (R1) required repositioning, incontinence care, and feeding assistance after return from hospitalization. R1 had a change in condition due to injury sustained on 10/20/21. Assistance was not provided in a timely manner. This poses a potential health and safety risk to residents in care.
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Request Denied
Type B
02/17/2022
Section Cited
CCR
87411(a)
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Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met by evidence of:
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Administrator agrees to submit a written plan that states how the deficiency was corrected.

In addition, staff shall receive training.
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Based on record review and interviews conducted between October 2021- January 2022 the facility has experienced staffing shortages. Resident (R1) required total care, but was not being checked by staff as indicated in the re-assessment.

This poses a potential health and safety risk to residents in care.

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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220111111836
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: PASADENA HIGHLANDS
FACILITY NUMBER: 198603384
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
02/04/2022
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.

This requirement is not met as evidenced by:
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Administrator shall ensure all med-tech staff distribute medications as directed.

Submit written proof of staff training and explain the steps taken to avoid future medication errors.

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Based on interviews conducted and record review on Jan. 1, 2022 (R1) was not administered evening medication as directed by MD. The meidications were administered late, were not crushed, and the wrong inhaler was taken to the room. Staff (S6) acknowledged medication error. This poses an immediate health and safety risk.
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Request Denied
Type B
02/17/2022
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities. In addition to ... Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Director agrees to submit a written plan stating how this was corrected, and what was done.

Submit proof of staff training and attach training topics.

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This requirement is not met as evidenced by:
Based on interviews and record review resident (R1) fell in the lobby area on 10/20/21. R1 was without assistance, but per Care Plan R1 requires escort assistance. This poses a potential Health and Safety risk to residents in care.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5