286803898-12-16-2020-21-AS-CMAZ-BX4RRY-20210109121556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286803898
Report Date: 12/15/2020
Date Signed: 12/16/2020 10:57:07 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2020 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20201112090750

FACILITY NAME:	PINK LADY CAREHOME, LLC.		FACILITY NUMBER:	286803898
ADMINISTRATOR:	ESPLANA B. ANGELINA		FACILITY TYPE:	740
ADDRESS:	39 VIA MARCIANA		TELEPHONE:	(707) 648-7983
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	94503
CAPACITY:	6	CENSUS:	DATE:	12/15/2020
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Jean Felix/Licensee		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident has stage 4 pressure injury

INVESTIGATION FINDINGS:

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Licensing Program analyst Leibert met with Licensee Jean Felix, this date for the purpose of delivering findings on the above captioned complaint allegation. The visit was conducted via tele-visit due to the COVID - 19 precautions. Resident (R1) has been on Hospice care since approximately February of 2020. At some point, R1 developed a bed sore that worsened over time and eventually was determined to be stage three. Records and interviews confirm that facility staff reported the progression of the sore to the Hospice nurses who notified the doctor. Records indicate that R1 was provided appropriate care for the wound and that the condition has been addressed in the Hospice Care Plan. R1's condition is permitted under "Exceptions for Health Conditions" Title Twenty-Two, 87616. Based upon the documents reviewed and the statements taken, the allegation is found to be UNFOUNDED, meaning that the allegation is false, did not happen, and/or is without a reasonable basis. Therefore the allegation is DISMISSED.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2020 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20201112090750

FACILITY NAME:	PINK LADY CAREHOME, LLC.		FACILITY NUMBER:	286803898
ADMINISTRATOR:	ESPLANA B. ANGELINA		FACILITY TYPE:	740
ADDRESS:	39 VIA MARCIANA		TELEPHONE:	(707) 648-7983
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	94503
CAPACITY:	6	CENSUS:	DATE:	12/15/2020
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Jean Felix/Licensee		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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8
9

Staff did not meet the needs of the resident
Correct refund was not issued to Responsible Person

INVESTIGATION FINDINGS:

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Licensing Program analyst Leibert met with Licensee Jean Felix, this date for the purpose of delivering findings on the above captioned complaint allegation. The visit was conducted via tele-visit due to the COVID - 19 precautions. It has been alleged that resident R1 has not been turned regularly in bed and that, after R1's replacement in another facility, the refund from the facility was not the correct amount. During the course of this investigation this Department has taken statements and reviewed documents. The following determinations have been made: Facility records indicate R1 was turned every two hours and staff concur; Hospice nurses who visited the facility did not express concern with R1's care; R1 did develop a stage three pressure injury while at the facility; there are differing opinions regarding the amount of refund due; R1's Responsible Person claims that RP was not allowed into the facility to timely remove R1's belongings; Administrator claims that the refund is appropriate because RP chose not to remove R1's belongings for 3 days which lowered the refund amount due. Based upon the documents reviewed and statements taken, the allegations may be true, or valid, but there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the complaint is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2020 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20201112090750

FACILITY NAME:	PINK LADY CAREHOME, LLC.		FACILITY NUMBER:	286803898
ADMINISTRATOR:	ESPLANA B. ANGELINA		FACILITY TYPE:	740
ADDRESS:	39 VIA MARCIANA		TELEPHONE:	(707) 648-7983
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	94503
CAPACITY:	6	CENSUS:	DATE:	12/15/2020
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Jean Felix/Licensee		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
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7
8
9

Staff did not share accurate observations with the Responsible Party

INVESTIGATION FINDINGS:

1
2
3
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5
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7
8
9
10
11
12
13

Licensing Program analyst Leibert met with Licensee Jean Felix, this date for the purpose of delivering findings on the above captioned complaint allegation. The visit was conducted via tele-visit due to the COVID - 19 precautions. It is alleged that when R1's condition changed due to the progression of the pressure injury that facility staff did not notify the Responsible Party. When questioned by this Department's staff, both the Hospice nurse and facility Administrator stated that the RP was not notified of the R1's change in condition until a care conference in November 2020 which was several months after the condition changed. Based upon the documents reviewed and statements made, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20201112090750

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PINK LADY CAREHOME, LLC.	FACILITY NUMBER: 286803898
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/24/2020 Section Cited CCR 87463(b)	1 2 3 4 5 6 7	87463 REAPPRAISALS. The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. ****Based upon statements made, this requirement has not been met as evidenced by: Facility did not notify Responsible Person when the condition	1 2 3 4 5 6 7	Administrator to develop and submit written protocols that will insure that changes of conditions are reported as required by regulation. Submit to CCL by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	of R1's pressure injury changed. This posed a potential risk to the health of R1.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 4