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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003003
Report Date: 01/11/2023
Date Signed: 01/11/2023 11:21:52 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, 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
10/10/2022 and conducted by Evaluator Claudia Gutierrez
COMPLAINT CONTROL NUMBER: 22-AS-20221010154451
FACILITY NAME:ADAMS FAMILY HOME, SHOSHONIFACILITY NUMBER:
306003003
ADMINISTRATOR:NANCY ADAMSFACILITY TYPE:
740
ADDRESS:418 SHOSHONI AVENUETELEPHONE:
(714) 996-2139
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 4DATE:
01/11/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Alfredo GambolTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Resident sustained injuries while in care.

Resident was left in a soiled diaper for a long period of time.

Staff not repositioning resident.
INVESTIGATION FINDINGS:
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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above for the purpose of delivering findings. LPA met with Staff 1 (S1) Alfredo Gambol.

Interviews were conducted with Reporting Party (RP), two witnesses, and facility staff, regarding allegation resident sustained injuries while in care. RP stated Resident 1 (R1) had “deep tissue injury on the buttocks.” Witness 1 (W1) stated “they are moisture related injuries,” and “it could be from sweat.” W1 further stated R1 also has cellulitis on their legs, “so it's nothing new.” W2 stated R1 had a bed sore and said they would not consider it an injury. LPA obtained and reviewed hospital medical records for R1 which reported R1 was admitted on 10/12/22 with cellulitis of the leg and increasing redness in the thighs, calves, and buttocks. R1 had “no current deep wounds.” (Cont. LIC9099-C)
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
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 3
Control Number 22-AS-20221010154451
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: ADAMS FAMILY HOME, SHOSHONI
FACILITY NUMBER: 306003003
VISIT DATE: 01/11/2023
NARRATIVE
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Per hospital medical documentation “examination of extremities reveal marked skin disruption on both legs with a yellowish crusting and excoriation and redness of both legs from the thighs to the feet,” and R1 had “some minor ulceration, including a larger ulcer on the right lateral ankle and some skin tear on the inner thigh. Still no deep wounds.” LPA also reviewed R1’s physician report dated 1/22/19 which states R1 has a history of skin condition/breakdown.

Interviews were conducted with RP, two witnesses, and facility staff regarding allegation resident was left in a soiled diaper for a long period of time. RP stated R1 had been soiled for a long period of time because their shirt was “soiled in urine." Two out of two witnesses reported that R1 has a catheter. W1 stated they did not know if R1 had been left in a soiled diaper for a long period of time but said R1 has an order for their catheter to be changed every 2 weeks which “isn't standard practice. Normally catheters are changed every 4 weeks to prevent clogging." W2 stated R1’s diaper is “only for bowel movements” and said the tubing associated with R1’s catheter was leaking and “that was the problem.” Staff 1 (S1) also stated R1’s catheter had been leaking. S1 stated an incontinence log is not kept however they “always check,” if resident’s diaper is not soiled then it is not changed. Resident 2 (R2) was asked if they are assisted with activities of daily living and could not corroborate the allegation.

Interviews were conducted with Reporting Party (RP), two witnesses, and facility staff regarding allegation staff not repositioning resident. All parties interviewed stated R1 is able to make their needs known. Per RP, R1 stated they are not being repositioned. One out of two witnesses stated R1 had told them they are being repositioned. S1 stated R1 is alert and does not like to be repositioned. Per S1, R1 “always wants to be comfortable.” LPA conducted an interview with R1, who could not corroborate allegation resident sustained injuries while in care. Furthermore, R1 stated they are assisted with activities of daily living and stated they “don’t need” to be repositioned.

Due to conflicting information received during interviews conducted and after a review of R1’s files, and hospital medical records, LPA is unable to determine if Resident sustained injuries while in care, if Resident was left in a soiled diaper for a long period of time, or if Staff did not reposition resident. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore at this time the above allegations are unsubstantiated.
(Cont. LIC9099-C)
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20221010154451
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: ADAMS FAMILY HOME, SHOSHONI
FACILITY NUMBER: 306003003
VISIT DATE: 01/11/2023
NARRATIVE
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An exit interview was conducted with S1 Alfredo Gambol and a copy of this report was provided at the end of the visit.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3