306001818-7-27-2021-22-AS-MSTC-CUWVDR-20230821162107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001818
Report Date: 07/27/2021
Date Signed: 07/27/2021 03:58:18 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/12/2021 and conducted by Evaluator Lydia Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210212112450

FACILITY NAME:	D'BEST CARE		FACILITY NUMBER:	306001818
ADMINISTRATOR:	MA DINAH DELA CRUZ		FACILITY TYPE:	740
ADDRESS:	3608 W. ASH AVENUE		TELEPHONE:	(714) 278-0528
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	6	CENSUS: 2	DATE:	07/27/2021
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Ma Dinah Dela Cruz		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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* Resident developed multiple stage 4 pressure injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced complaint visit to deliver findings on the above allegation. LPA identified herself and discussed the purpose of the visit with Administrator Ma Dinah Dela Cruz. The complaint was investigated by Community Care Licensing Investigations Branch (IB).

During the investigation, interviews were conducted with facility Administrator, staff and witnesses. Additionally, copies of Green Meadows Health Care medical records (certification period: 01/01/2021 – 03/01/2021) for Resident 1 (R1) and UCI Irvine Health medical records dated 02/06/2021, were obtained and reviewed.

The investigation revealed the following: R1 is an 83-year-old diagnosed with Dementia, residing at the facility since 12/30/2020. R1 was receiving home care services from Green Meadows Home Health for physical therapy after having surgery on the right knee.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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

Control Number 22-AS-20210212112450

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: D'BEST CARE	FACILITY NUMBER: 306001818
	VISIT DATE: 07/27/2021

NARRATIVE

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On or about 01/20/2021, R1 began to develop small ulcers on coccyx due to lack of mobility. A Home Health Licensed Vocational Nurse (LVN) was assigned to continue providing services and also began treating the pressure ulcers. Administrator stated that rotating R1 side to side, R1 began developing skin tears on both sides of the hips. On 01/19/2021, Administrator stated she requested from Home Health a wound specialist to see R1. On 01/26/2021 Home Health LVN told Administrator she believed R1’s wound was improving, and no wound specialist was recommended. Home Health LVN requested an air mattress for R1 and continued treating the ulcers and reporting to the physician. On or about 01/29/2021, R1 developed additional small ulcers across the lower extremities across left hip to right hip and the ulcer on coccyx had developed into a stage two. Home Health LVN along with facility caregivers attempted to treat the ulcers by continuing to rotate R1. On 02/04/2021, Home Health LVN requested that R1 be evaluated by Green Meadows Home Health Nurse Practitioner (NP) and another Home Health LVN. It was determined by the NP that R1’s pressure ulcer on coccyx had worsened but was going to wait for a wound specialist on 02/05/2021 to evaluate and treat the ulcers. On 02/06/2021, facility Administrator sent R1 to the hospital because no wound specialist had come out and Home Health LVN said R1’s ulcer developed to a stage four and had worsened. The facility requested numerous times to have R1 be seen by a wound specialist or a physician. They documented daily R1’s status and services they provided. The facility did not call 911 when staff observed R1’s change in condition and their inability to lift or move R1. In addition, Administrator stated facility was short staffed due to COVID-19 and aware R1 required two-person transfer. R1’s assessment was done via phone. Facility was aware of R1’s health condition (heart failure, hypertension, sensitive due to skin cancer, history of bed sores, no mobility due to knee surgery, cellulitis of right and left limbs, muscle weakness) per Appraisal/Needs and Services Plan dated 01/01/2021. Green Meadows Home Care prolonged the request of a wound specialist which never came and requested an air mattress which never came. The facility made the decision to send out R1 to UCI Health Care Hospital on 02/06/2021 because his ulcers worsened to a stage four rather than continue home care services. The facility is responsible overall for the condition and well being of the resident and should have provided timely medical attention sooner regardless of R1 receiving Home Care services. Both facility and Green Meadows Home Care failed to provide timely medical attention subjecting R1 to immediate decline in health and unnecessary pain and suffering.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division 6), is being cited on the attached LIC 9099-D.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20210212112450

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: D'BEST CARE	FACILITY NUMBER: 306001818
	VISIT DATE: 07/27/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49 An exit interview was conducted with Administrator and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) and LIC811.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20210212112450

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: D'BEST CARE	FACILITY NUMBER: 306001818
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/29/2021 Section Cited CCR 87464(f)(6)	1 2 3 4 5 6 7	Basic Services…(f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator states will conduct in-service training on section cited. Will provide proof of training to CCL by 08/06/2021.
	8 9 10 11 12 13 14	Based on interviews conducted and record reviews, R1 developed stage IV pressure injury under facility’s care. Facility did not provide timely medical attention to R1. This poses an immediate risk to the health & safety of the resident in care.	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: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4