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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603504
Report Date: 05/17/2024
Date Signed: 05/17/2024 02:14:49 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
01/31/2023 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230131141908
FACILITY NAME:LA POSADAFACILITY NUMBER:
198603504
ADMINISTRATOR:DIANA BAUTISTAFACILITY TYPE:
740
ADDRESS:8120 PAINTER AVETELEPHONE:
(562) 945-2651
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:114CENSUS: 86DATE:
05/17/2024
UNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Diana Bautista-Martinez, Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Resident sustained a fracture while in care.
Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent visit in response to the above-mentioned allegations. LPA met with Executive Director, Diana Bautista-Martinez and explained the reason for the visit.

Investigation consisted of the following: On 02/01/2023, LPA Pena conducted a health and safety check, tour of the facility's common areas and requested a copy of the Staff roster and Resident roster. LPA also reviewed and obtained files for Resident #1 (R1). LPA did not observe any immediate Health and/or Safety concerns.

On 2/27/2023, LPA Pena conducted a subsequent visit and obtained copies of the current Staff/Resident rosters, interviewed Resident #2-Resident #9 (R2-R9), Staff #1-Staff #7 (S1-S7), attempted to interview a potential witness (W1) but phone number was no longer in service. LPA also checked a random resident's MAR/medication and toured the medication room. LPA delivered findings for the other allegations.

On today's visit, LPA obtained copies of the current Staff & Resident rosters, delivered findings and issued deficiencies and civil penalty. *****CONTINUED ON LIC9099-C*****
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
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 4
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
01/31/2023 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230131141908

FACILITY NAME:LA POSADAFACILITY NUMBER:
198603504
ADMINISTRATOR:DIANA BAUTISTAFACILITY TYPE:
740
ADDRESS:8120 PAINTER AVETELEPHONE:
(562) 945-2651
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:114CENSUS: 86DATE:
05/17/2024
UNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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9
Resident sustained a fracture while in care.
Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
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In regards to the allegation: “Resident sustained a fracture while in care.” It is alleged that Resident #1 (R1) sustained a left hip fracture as a result of a fall while under the care of the facility. This allegation was investigated and completed by Investigator Santana with the Investigations Branch. R1 was admitted to the facility on 9/29/2022 and was already known to be a fall risk because of her poor and unsteady gait, osteoporosis of both knees, walker use, and dementia diagnosis. R1 was placed in the assisted living section of the facility. R1 fell on 10/01/2022 and hit her head while ambulating but did not sustain injury and declined hospitalization. In response to this incident, the facility placed R1 in the memory care unit during waking hours for increased supervision and was moved there permanently on 10/10/2022. Because R1 exhibited constant agitation and escape-seeking by getting out of her wheelchair and walking to doors and windows, the facility attempted to keep R1 in the common area, redirect, and administer as-needed medications for anxiety. R1’s aggression did not subside despite her receipt of two doses of Ativan daily since 10/10/2022. As of 10/13/2022, the facility began administering Ativan to R1 at 0600 hours. ****CONTINUED ON LIC9099-C*****
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230131141908
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: LA POSADA
FACILITY NUMBER: 198603504
VISIT DATE: 05/17/2024
NARRATIVE
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When an overnight shift caregiver last checked on R1 at 0530 hours on 10/14/2022, she noted R1 was fine. A staff entered R1’s bedroom at 0600 hours to give her Ativan as a matter of course, not because of documented agitation, and it appears R1 was left in bed after the interaction. The majority of staff interviews conducted revealed that R1 was always checked first at the beginning of the morning shift (0600 hours) precisely because of being a fall risk. It is unclear why R1 would be left unattended in her bedroom after she was known to be awake. A morning shift staff documented that her first check was at 0630 hours, but based on an Internal Incident Report, this staff checked on R1 at 0700 hours, which is more consistent with her past checks but still within the facility’s safety check window of every two hours. Though R1 appears to have fallen in between staff rounds, sometime between 0600 and 0700 hours, her wandering behavior and attempts to get out of bed without assistance should have warranted attention. R1 was transported to the hospital and was diagnosed with a left hip fracture for which she underwent a left hemiarthroplasty. The allegation facility Neglect/Lack of Supervision resulted in R1’s fall is therefore Substantiated.
In regards to the allegation: “Staff did not seek medical attention for resident in a timely manner.” It is alleged that R1 did not receive timely medical attention after suffering a fall and being in pain for several days. This allegation was investigated and completed by Investigator Santana with the Investigations Branch. Interviews conducted revealed that after R1 was found on her bedroom floor sometime between 0600-0700 hours on 10/14/2022, S3 assessed R1 and concluded she had not sustained injury, since there was no visible injury and R1 was able to take a few steps with her walker without complaining of any pain. S3 did not call 911 despite the fall having been unwitnessed because there was no apparent injury and R1 was on hospice, but S1-S2 conceded that the S3 should have called 911 even though R1 was on hospice because of uncertainty about whether R1 hit her head. S3 instead notified VITAS Hospice, likely at 0805 hours that same day, but a VITAS nurse did not arrive to assess R1 until 10/17/2022. Interviews, facility phone records, and VITAS records suggest the facility did not inform VITAS about R1’s change of condition despite calls from VITAS nurse on 10/15/2022 and 10/16/2022 to ask about R1. R1’s change of condition was evident based on facility staff member interviews and documentation, noting that after the fall, R1 was no longer attempting to get up from her wheelchair to bang on windows, which she had done as recently as the day prior. Additionally, R1 was noted as being sleepy and as sleeping the majority of the day on the three days following the fall. While the facility suggested this lethargy could have been attributed to Ativan, R1 had been taking the same amount of Ativan since 10/10/2022, when R1 was still agitated. A VITAS nurse assessed R1 on 10/17/2022 but did not get R1 out of bed. When a staff attempted to get R1 out of bed, at family member’s request, on the afternoon of 10/17/2022, R1 screamed out “in excruciating pain,” saying her back hurt. R1 was transported to the hospital on 10/17/2022 for congestion and left lower abdominal pain and was found to have a fractured left hip that was within two weeks old. R1 ultimately underwent a hip replacement. Had the facility called 911 on 10/14/2022, it is likely R1 could have been treated sooner. The allegation that facility Neglect/Lack of Supervision contributed to a delay in obtaining medical attention for R1 is therefore Substantiated.


***An immediate civil penalty will be issued today, in the amount of $500 due to neglect/lack of supervision which contributed to a delay in obtaining medical attention in which resident sustained a hip fracture. ***

At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date.

An exit interview was conducted, and a copy of this report was provided to the Administrator along with the Appeals Rights.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230131141908
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: LA POSADA
FACILITY NUMBER: 198603504
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in 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: (4) 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.
This requirement is not met as evidenced by:

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Licensee/Administrator shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87468.2(a)(4). Written POC must be submitted to CCL/LPA by POC due date.
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Based on interviews, records review conducted by Investigator Santana, the licensee did not comply with the section cited above in which due to lack of care and supervision, R1 sustained a left hip fracture as a result of a fall while under the care of the facility.
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Type A
05/21/2024
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents...(a) In addition to the rights listed in 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:(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
This requirement is not met as evidenced by:

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Licensee/Administrator shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87468.2(a)(1). Written POC must be submitted to CCL/LPA by POC due date.
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Based on interviews, records review conducted by Investigator Santana, the licensee did not comply with the section cited above in which due to lack of care and supervision contributed to a delay in obtaining timely medical attention for R1.
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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4