198603504-10-10-2024-28-AS-RORN-DAJNT6-20241030104409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603504
Report Date: 10/10/2024
Date Signed: 10/10/2024 04:23:30 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
07/25/2024 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240725102607

FACILITY NAME:	LA POSADA		FACILITY NUMBER:	198603504
ADMINISTRATOR:	DIANA BAUTISTA		FACILITY TYPE:	740
ADDRESS:	8120 PAINTER AVE		TELEPHONE:	(562) 945-2651
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90602
CAPACITY:	114	CENSUS: 86	DATE:	10/10/2024
		UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Diana Bautista, Administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Facility staff are not making arrangements to meet residents' health needs.
Facility staff are not ensuring that residents are receiving an annual medical assessment as required.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations and deliver findings. The purpose of the visit was discussed with Wellness Director. Administrator Diana Bautista arrived shortly after.

The investigation consisted of: On 7/25/24, LPA interviewed resident (R1). On 8/23/24, staff (S1-S3) were interviewed and additional documents were reviewed/collected. During today's visit, record review was completed and residents (R2- R7) were interviewed. Records collected were: Face Sheet/Identification and Emergency Information, Preplacement Appraisal, Resident Appraisal, Needs and Services Plan [12/12/22], Physician's Report [12/6/22], Hospice orders, Physician's Orders, ALW Individual Service Plan (ISP), Home Healthnotes, Physician Communication (6/13/24), Admission Agreement, Charting Notes, resident roster and LIC 500 Personnel Report.
During the course of the investigation, R1's authorized representative was interviewed. Mulitple attempts to interview R1's Medical Doctor were made.

*** Narrative continues next page.

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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-20240725102607

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: LA POSADA	FACILITY NUMBER: 198603504
	VISIT DATE: 10/10/2024

NARRATIVE

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Allegation: Facility staff are not making arrangements to meet residents' health needs. It was reported that resident (R1's) primary care physician informed staff that the resident's healthcare plan was contacted requesting a Cardiologist and Pulmonologist consult, but the facility did not follow through because staff stated that they do not provide transportation to medical appointments. Based on record review, resident (R1) has had a decline in health during the past year, and was hospitalized from June 21, 2024 - June 24, 2024 and placed on home health upon return to the facility. The resident had been enrolled in home health services earlier in the year. Per record review, on July 9, 2024, there was communication between Wellness Director and R1's Medical Doctor, in which MD informed staff that a Cardiologist and Pulmonologist consult referral was sent to R1's insurance provider, as well as a transportation referral. Three staff were interviewed, they confirmed the facility got verbal notification from Medical Doctor that R1 required a Cardiologist and Pulmonologist consult, but stated that they did not receive written referral information for the specialists. Facility charting notes confirm that R1's Doctor informed staff. Resident (R1's) family member was interviewed. They confirmed R1 has not been seen by specialist doctors and was not notified by facility staff that the primary care physician made the facility aware of the referrals on July 9, 2024. Therefore, the residents health needs are not being met.

Allegation: Facility staff are not ensuring that residents are receiving an annual medical assessment as required. According to information obtained on June 13, 2024, facility med-tech staff contacted resident (R1's) primary care physician requesting medication refills for 4 medications. However, R1's physician informed staff that the resident has not been seen at the doctor's office in over 2 years. Therefore, the medications would not be refilled. Records indicate the resident moved in 12/12/2022, and upon move-in a Physician's Report dated 12/6/2022 was obtained. A total of 7 residents were interviewed, none reported issues pertaining to the allegation. Based on record review, resident (R1) has mild cognitive impairment and no Dementia. However, record review and staff interviews revealed that resident (R1) was sent out to urgent care in December 2023. A change in condition was noted. On 2/21/2024, the resident was enrolled in home health services, and was sent out to the hospital in early March 2024. In May 2024, staff observed physical changes in need of medical attention. On June 21, 2024, R1 was sent out to the hospital and returned on June 24, 2024, with physical therapy physician order. On July 22, 2024, R1 was enrolled in hospice care. Staff acknowledged R1 had changes in condition since early January 2024, but did not the contact the resident's primary care physician to schedule an annual medical exam. LPA conducted a visit on 7/25/2024 and collected R1's Physician's Report dated 12/6/2022. After that visit, staff obtained an updated Physician's Report dated (7/29/2024) from hospice MD, which indicates the resident has heart failure and requires total care. Staff observed deterioration of physical health condition for months but did not bring to the attention of R1's physician.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22. See LIC 9099D.

Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20240725102607

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: LA POSADA	FACILITY NUMBER: 198603504
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/17/2024 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.	1 2 3 4 5 6 7	Administrator agreed to: 1. Submit proof the MD specialist consult appointments have been scheduled. 2. Submit a written plan of correction. 3. Conduct med-tech staff training on physician referral follow-up protocols, note charting, and requesting updated physician's reports when there is a change in condition.
	8 9 10 11 12 13 14	Based on record review and interviews conducted, the findings indicate that R1 had a decline in health since Jan. 2024, with change in condition, which prompted R1's doctor to inform staff on 7/9/24, that a Cardiologist and Pulmonologit consult was needed. Per record review, staff did not follow up or obtain referral documentation.	8 9 10 11 12 13 14
Type B 10/17/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident . The licensee shall ensure ...When changes ... or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	Administrator stated that on 7/30/24, facility requested an updated Physician's Report from hospice MD. 1. Submit proof that all caregiver and med-tech staff were trained in regulation 87466, and change in condition.
	8 9 10 11 12 13 14	Based on record review, staf observed deterioration of physical health condition in R1 since early Jan. 2024, but did not bring to the attention the resident's change in condition, nor was a medical exam requested. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

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