306002279-8-4-2021-22-AS-MSTC-C65VKW-20210822163101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002279
Report Date: 08/04/2021
Date Signed: 08/04/2021 02:46:04 PM

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
07/29/2020 and conducted by Evaluator Shobhana Frank

COMPLAINT CONTROL NUMBER: 22-AS-20200729111159

FACILITY NAME:	SHANGRI-LA RCE #1		FACILITY NUMBER:	306002279
ADMINISTRATOR:	MYRIAM EGGERS		FACILITY TYPE:	740
ADDRESS:	4612 RHAPSODY DR.		TELEPHONE:	(714) 377-3902
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92649
CAPACITY:	6	CENSUS: 6	DATE:	08/04/2021
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Administrator (AD) Myriam Eggers		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Neglect/Lack of Supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Administrator (AD) Myriam Eggers and explained the purpose of the visit. The complaint was investigated by Community Care Licensing Investigations Branch (IB).

During the investigation, interviews were conducted with Resident 1 (R1) Son, Social Worker of Salus Hospice, Hospice Nursing Supervisor, Hospice Nurse, Licensee, Administrator. Additionally, copies of R 1’s Fountain Valley Regional Hospital Medical Records dated 7/22/20, 7/24/20 and 8/11/20; Salus Hospice Medical Records from 6/18/20 to 8/6/20; R1’s physician’s report dated 7/18/19, pre-appraisal report 8/19/19; appraisal report dated 7/27/20; Special Incident Reports dated 7/22/20, 7/27/20 and 8/3/20; Evidence report LIC 9057 dated 10/27/20 were obtained and reviewed.
The investigation revealed the following:
R1 was admitted to the facility on 07/20/19. R1 is legally blind, has dementia, heart problems, diabetes and was non-ambulatory. R1 had a stage four ulcer on her left heel. R1 was placed at the facility from 07/20/19 to

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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 22-AS-20200729111159

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: SHANGRI-LA RCE #1	FACILITY NUMBER: 306002279
	VISIT DATE: 08/04/2021

NARRATIVE

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07/22/20. While at the facility. R1 developed a blister on her left heel as a result of the shoe she was wearing, and facility personnel treated the heel. Administrator Myriam Eggers contacted R 1’s physician and reported the blister was not healing. It took Dr. Christopher Nguyen two weeks before sending a nurse to the facility. Dr. Nguyen sent a nurse with Salus Hospice Home-Health to look at the wound. Registered Nurse Helen Le told the administrator and R1’s son, that the wound was a stage III ulcer. From 06/22/20 to 08/02/20, Salus Hospice nurse were treating the wound. On 07/22/20, when Salus Hospice nurse told facility staff members that the wound was a stage IV ulcer, they were very surprised. During the interview on 10/26/20 Salus Hospice Nursing Supervisor Kimberly Tulley reported that the facility personnel were not responsible for wound care since R 1 was on Hospice and Home-Health. Facility personnel provided wound care and followed directives from hospice and home health. Facility personnel informed R 1’s son and the doctor about the wound.

Based on the information gathered during the investigation, which involved interviews and review of all documents obtained, the Department is unable to ascertain if the allegations mentioned above occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation of Neglect/Lack of Care and Supervision is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC9099 (FAS) - (06/04)

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