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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 270708716
Report Date: 05/27/2022
Date Signed: 05/28/2022 09:06:04 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2020 and conducted by Evaluator Marybeth Donovan
COMPLAINT CONTROL NUMBER: 26-AS-20201022154232
FACILITY NAME:VISIONARY CARMEL-BY-THE-SEA ASSISTED LIVINGFACILITY NUMBER:
270708716
ADMINISTRATOR:CONNERS, MARGARET P.FACILITY TYPE:
740
ADDRESS:LINCOLN & 7TH STREETTELEPHONE:
(831) 644-9246
CITY:CARMELSTATE: CAZIP CODE:
93921
CAPACITY:10CENSUS: 7DATE:
05/27/2022
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Angelique RobinsonTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident sustained multiple bruising while in care
Facility staff did not seek medical treatment for resident in care
Staff are not ensuring residents getting their daily nutrition
Unusual Incident reports are not documented
Staff not helping residents with incontinence needs
Staff made inappropriate comments to residents

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the complaint investigation findings related to the above allegations. LPA met with Angelique Robinson Administrator and explained the purpose of the visit.

Resident sustained multiple bruising while in care:
Family member noticed resident R1 had bruises on R1’s legs that R1 may have got from accidentally hitting something. Family member said R1 did not have any concerning marks on R1 when R1 lived at the facility. On 10/27/2020 staff member told family member that R1 had an open sore on R1’s buttocks area. Family member had not been previously notified by staff about the sore. Administrator was not aware of R1 having bruise on R1’s left hip or fingerprint marks on R1’s right and left knee and four red bruises on R1’s upper mid thighs as stated in the complaint.

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Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
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 9
Control Number 26-AS-20201022154232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: VISIONARY CARMEL-BY-THE-SEA ASSISTED LIVING
FACILITY NUMBER: 270708716
VISIT DATE: 05/27/2022
NARRATIVE
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6 of 7 staff never observed any bruises on R1. 1 Staff (S1) noted in an incident report dated 10/12/2020 that R1 had a bruise on R1’s upper left thigh, and R1 was complaining that it hurt. The report stated that S1 worked the previous night and S1 did not notice the bruise and R1 was not hurting. On 10/29/2020 R1 met with medical doctor and had an x-ray of R1’s pelvis. The findings indicated no fractures.

Facility staff did not seek medical treatment for resident in care:
Administrator said resident R2 has had a sore near R2's left ear prior to being placed at the facility. Sometime in mid to late September, caregiver notified Administrator that the sore near R2’s left ear was slightly bigger and red. Administrator scheduled an appointment with medical doctor on 9/15/2020 to have R2’s ear checked. Administrator said the sore on R2’s ear was due to skin cancer. Primary care physician was first notified by facility staff member about R2’s ear wound during visit on 9/15/2020. Primary care physician had prior visits with R2 in August and September and did not previously notice the wound. R2’s family member (F2) first noticed the wound 2-3 weeks prior to 12/8/2020. F2 believed, R2 got the wound from picking at R2’s face.

Staff are not ensuring residents getting their daily nutrition:
Administrator and 7 staff were interviewed and stated that staff always provide meals, fluids and encourage residents to eat and drink fluids. Care Logs reviewed for August -October 2020 note staff monitoring residents’ food and water intake.

S1 stated that meals are prepared fresh. Meals include fresh fruit, proteins, and vegetables. Groceries are purchased monthly and fresh produce weekly or as needed. S5 stated that R1 sometimes did not want to eat. At times staff would assist R1 but R1 could eat on their own if they chose to. 3 of 6 residents stated that there are getting enough food and liquids. 3 of 6 resident were not able to respond to interview questions. Menus reviewed for 10/2020 and noted a selection of fruits, proteins and vegetables were included. Other menu options are provided. Staff try to prepare food items preferred by each resident. On 10/27/2020 LPA observed 6 Residents were having lunch in the dining room. A variety of foods to include hot dogs wrapped in a crescent roll (Pigs in the Blanket), fries, watermelon and peanut butter brownie with whipped cream.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 26-AS-20201022154232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: VISIONARY CARMEL-BY-THE-SEA ASSISTED LIVING
FACILITY NUMBER: 270708716
VISIT DATE: 05/27/2022
NARRATIVE
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Unusual Incident reports are not documented
Administrator denies not reporting incidents. Administrator stated that each incident is reviewed to determine if an incident report needs to be completed. A resident will be checked for signs of injury and pain. An incident that occurred in mid-September involving R1 was not written as R1 was not observed by staff to have any skin tears or bruising. S1 stated that staff note incidents, complete reports and forward to the Administrator for review. S2 notes incidents in the care logs and reports those to the Administrator but does not generate formal reports. S3 stated the administrator is responsible for all reporting.

Records review of Care Logs and Incident Reports were reviewed for the period of 8/1/2020 through 10/31/2020. Resident monitoring for change in condition and incidents were recorded in the care logs. Incident Reports involving injury or complaint of pain were generated and submitted to the Department.

Staff not helping residents with incontinence needs
Administrator denies residents incontinent needs are not being met. Administrator stated that staff are continually checking on residents to see if they need assistance with toileting or incontinence needs. The overnight staff do rooms checks every two hours. The room checks are not logged. 4 of 4 staff deny residents toileting or incontinent needs are not met. S1 stated that staff check on the residents frequently during the am, before and after meals. S3 stated that staff are aware of those residents that need additional monitoring and more frequent checks. 3 of 6 residents do not have issues with care provided.

Records review of Care Log for the period of 8/1/2020 through 10/31/2020 notes instances were room checks were completed to document additional monitoring of residents.

Staff made inappropriate comments to residents
Administrator and 4 staff were not aware or did not have direct knowledge of staff making inappropriate comments were made to residents. 3 of 3 residents did not have any concerns regarding care or staff.

Review of facility records, Incident reports and Care Logs, resident files did not note any incidents of inappropriate comments by staff to residents.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 26-AS-20201022154232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: VISIONARY CARMEL-BY-THE-SEA ASSISTED LIVING
FACILITY NUMBER: 270708716
VISIT DATE: 05/27/2022
NARRATIVE
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The Department has investigation the above complaint allegations. Based on information from interviews conducted and records reviewed, although the allegations listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22

Report reviewed with Angelique Robinson Administrator and a copy of this report provided.



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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2020 and conducted by Evaluator Marybeth Donovan
COMPLAINT CONTROL NUMBER: 26-AS-20201022154232

FACILITY NAME:VISIONARY CARMEL-BY-THE-SEA ASSISTED LIVINGFACILITY NUMBER:
270708716
ADMINISTRATOR:CONNERS, MARGARET P.FACILITY TYPE:
740
ADDRESS:LINCOLN & 7TH STREETTELEPHONE:
(831) 644-9246
CITY:CARMELSTATE: CAZIP CODE:
93921
CAPACITY:10CENSUS: DATE:
05/27/2022
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Angelique RobinsonTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident sustained a fracture while in care and the facility did not see timely medical attention
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the complaint investigation finding. LPA met with Angelique Robinson Administrator and explained the purpose of the visit.

The Department investigated the above allegation.

On 9/15/202 family member was told by staff that resident R1 had fallen in the facility three to four days prior. On 9/15/2020 family member (F1) took R1 to a medical appointment and it was discovered that R1 had a fracture of the right lower rib cage. Prior to 9/15/2020, family member was not contacted by the facility staff to let family member know R1 had fallen at the facility. Medical report stated R1 had an x-ray of R1's right ribs. The findings stated, “Oblique fracture of the distal 7th and 8th rib. The fracture is closed and displaced.” The facility failed to seek timely medical attention for R1.

Page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 26-AS-20201022154232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: VISIONARY CARMEL-BY-THE-SEA ASSISTED LIVING
FACILITY NUMBER: 270708716
VISIT DATE: 05/27/2022
NARRATIVE
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The Department investigation the above complain allegation. Based on interviews and records review, there is preponderance of evidence to prove the alleged violations did occur, therefore the allegation is SUBSTANTIATED.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22. Immediate Civil Penalty being assessed in the amount of $500.00.

Report reviewed with Angelique Robinson Administrator and a copy of this report and appeal rights provided.

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SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 9 of 9
Control Number 26-AS-20201022154232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: VISIONARY CARMEL-BY-THE-SEA ASSISTED LIVING
FACILITY NUMBER: 270708716
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2022
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities
a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Administrator to review the above Regulation regarding safe and healthful environment and submit a letter of understanding and conduct in-service training on 911 Protocols, When to Seek Medical Attention and Fall Prevention. Submit proof of completion to include date completed, participants and topic(s) discussed and submit plan to complete by POA date.

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This requirement was not met as evidenced by: Based on interviews and records review R1 fell at the facility, no immediate medical treatment sought. R1 sustained a rib fracture confirmed by medical report dated 9/15/2022 which poses an immediate risk to Health and Safety of resident in care.

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Immediate Civil Penalty being assessed in the amount of $500.00 for serious injury sustained by R1 resident 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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 9