306003482-1-24-2023-22-AS-SSAS-CNLUWX-20230131145728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003482
Report Date: 01/24/2023
Date Signed: 01/24/2023 02:54:25 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
09/23/2022 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220923152100

FACILITY NAME:	KAMSTRA CARE HOME		FACILITY NUMBER:	306003482
ADMINISTRATOR:	OSVALDO SANTA ANA		FACILITY TYPE:	740
ADDRESS:	5265 CANTERBURY DRIVE		TELEPHONE:	(562) 637-3392
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90630
CAPACITY:	6	CENSUS: 6	DATE:	01/24/2023
		UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Runette Catibog - Administrator		TIME COMPLETED:	02:54 PM

ALLEGATION(S):

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Resident developed a pressure injury while in care
Facility did not notify resident's family of change in resident's medical condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings of the investigation into the above allegations. LPA Velazquez was allowed entry into the facility and met with Administrator (ADMIN) Runette Catibog and explained the purpose of the visit.

On today's visit LPA Velazquez along with ADMIN Catibog looked in on the 6 residents in care. The residents appeared well-groomed and well-cared for. One resident was watching TV in the living room, the other 5 residents were either sleeping or resting in their rooms. During the course of the investigation the following was revealed: Regarding the allegation: Resident developed a pressure injury while in care, LPA Velazquez conducted interviews with the complainant, Resident (R) #2’s family, residents, and staff. LPA Velazquez also reviewed and obtained copies of pertinent documents. The records reviewed included medical records from Los Alamitos Medical Center including photographs taken in the Emergency Department of R2’s pressure injuries, PIH Hospice of Presbyterian hospice records, Physician’s Reports, Advanced Health Care Directive,

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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-20220923152100

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: KAMSTRA CARE HOME	FACILITY NUMBER: 306003482
	VISIT DATE: 01/24/2023

NARRATIVE

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Resident Appraisals, Preplacement Appraisal Information forms, and Admission Agreements. R2 was sent out to the hospital on September 22, 2022 due to difficulty breathing. At Los Alamitos Medical Center R2 was diagnosed with Acute Cystitis, Acute Hyperglycemia, Severe Anemia, Severe Sepsis among other conditions. While at Los Alamitos Medical Center additional consultation by a Social Worker was requested due to the presence of a pressure injury on R2’s sacral region as well as redness on one of R2’s heels. Four of four individuals interviewed were able to corroborate the allegation: Resident developed a pressure injury while in care.

Regarding the allegation: Facility did not notify resident's family of change in resident's medical condition the following was revealed: LPA Velazquez conducted interviews with the complainant, Resident (R) #2’s family, residents, and staff. LPA Velazquez also reviewed and obtained copies of pertinent documents. The records reviewed included medical records from Los Alamitos Medical Center including photographs taken in the Emergency Department of R2’s pressure injuries, PIH Hospice of Presbyterian hospice records, Physician’s Reports, Advanced Health Care Directive, Resident Appraisals, Preplacement Appraisal Information forms, and Admission Agreements. When interviewed two of two facility staff stated R2 had no pressure injuries prior to being sent out to the hospital. R2's facility documentation indicated R2 "no bed sores" which Administrator Catibog confirmed. R2's family first became aware of R2's pressure injuries in the Emergency Department when R2 was transported via ambulance to Los Alamitos Medical Center on September 22, 2022. Per Administrator Catibog an Unusual Incident/Injury Report (LIC 624) was not submitted to Community Care Licensing Division pursuant to statute and regulation regarding R2's hospitalization.

Based on the observations of LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Resident developed a pressure injury while in care and Facility did not notify resident's family of change in resident's medical condition are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator Runette Catibog and a copy of this report along with the appeal rights, LIC 811, and LIC 9098 were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20220923152100

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: KAMSTRA CARE HOME	FACILITY NUMBER: 306003482
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 01/25/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services. Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: based on record review and interviews the licensee did not observe R2's change in condition with R2's pressure injuries. This poses an immediate risk to the health & safety of residents in care.	1 2 3 4 5 6 7	The Licensee will provide staff an in-service training regarding this regulation by 01/25/23. Licensee to provide the name of the instructor, their qualifications, and submit written proof of the staff training to LPA by POC due date.
Request Denied Type A 01/25/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional...and that appropriate assistance...when such observation reveals unmet needs...licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person (RP). This requirement is not met as evidenced by: based on record review and interview the licensee did not observe R2's pressure injuries and did not notify R2's RP. This poses an immediate risk to the health and safety of residents in care.	1 2 3 4 5 6 7	The Licensee will provide staff an in-service training regarding this regulation by 01/25/23. Licensee to provide the name of the instructor, their qualifications, and submit written proof of the staff training to LPA by POC due date.
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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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC9099 (FAS) - (06/04)

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