306003823-10-8-2020-22-AS-SSAS-BUN4EH-20201022190218

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003823
Report Date: 10/08/2020
Date Signed: 10/08/2020 02:38:05 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
06/24/2020 and conducted by Evaluator Albert Marin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200624141017

FACILITY NAME:	ADRIANA ELDERLY CARE HOME IV		FACILITY NUMBER:	306003823
ADMINISTRATOR:	MENDOZA, ADRIANA		FACILITY TYPE:	740
ADDRESS:	24851 ARGUS DRIVE		TELEPHONE:	(949) 600-5734
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	10/08/2020
		UNANNOUNCED	TIME BEGAN:	01:11 PM
MET WITH:	Administrator Richard Mendoza		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Resident developed pressure injuries while in care.
Staff could not communicate with resident and responsible parties.

INVESTIGATION FINDINGS:

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Due to COVID-19 and as pre-cautionary measures, Licensing Program Analyst (LPA) Albert Marin made an unannounced video teleconference visit to deliver the findings on a complaint investigation . LPA met with Administrator (AD) Richard Mendoza Sr. The following are the findings of the investigation.

On June 24, 2020 the Department received a complaint alleging that the resident developed pressure injuries while in care. Resident 1 (R1) was admitted in this facility on February 19, 2020. Based on records reviewed, the physician’s report dated February 9, 2020 indicates R1 health diagnosis includes Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus Type II, Congestive Heart Failure, and Osteomyelitis (inflammation in the bone) status post right below the knee amputation. On May 14, 2020, R1 was admitted to hospice care due to COPD. On admission to hospice, per medical records, R1 had a poor body strength, poor appetite with chronic back and right lower extremity pain. (Continuation in Page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

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-20200624141017

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: ADRIANA ELDERLY CARE HOME IV	FACILITY NUMBER: 306003823
	VISIT DATE: 10/08/2020

NARRATIVE

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(Continuation from Page 1) Throughout the course of resident being under hospice care, R1 received regular wound care for unstageable wound pressure injury and chronic open surgical wound at the back. Regular wound care was routinely done with no signs of infection. Due to declining health of R1, additional pressure injuries were later observed and managed. R1 passed away on June 22, 2020 and death certificate indicated the cause of death was Chronic Obstructive Pulmonary Disease.

On June 24, 2020 the Department also received a complaint alleging that staff could not communicate with resident and responsible parties. Based on file review and interviews, five out of five witnesses interviewed stated that they encountered no communication or care issues with the facility staff and administrators. Per medical records, although with routine pain medications, R1 experienced intermittent episodes of pain and were managed either by as needed medications or medication adjustments. No observation was recorded that facility staff failed to understand or follow the care instructions given by the hospice agency staff.

Based on the information gathered during the investigation conducted by the Investigation Branch (IB), 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, these allegations are deemed UNSUBSTANTIATED.

An exit interview was conducted. LPA Marin read this report to Administrator Richard Mendoza, Sr. and a copy of this report will be provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

LIC9099 (FAS) - (06/04)

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