306003840-6-22-2023-22-AS-AORZ-CTPQ4M-20230713115034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003840
Report Date: 06/22/2023
Date Signed: 06/22/2023 02:14:44 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
04/19/2022 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220419091443

FACILITY NAME:	GRACIOUS CARE HOMES		FACILITY NUMBER:	306003840
ADMINISTRATOR:	DAVID NEHEM/S.MITCHELL		FACILITY TYPE:	740
ADDRESS:	4110 E. JORDAN AVENUE		TELEPHONE:	(714) 289-1946
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	6	CENSUS: 6	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Joselene Poy lorenzo, Caregiver		TIME COMPLETED:	02:08 PM

ALLEGATION(S):

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-A resident eloped from the facility and the caregiver did not know he was gone.
-Facility lacks care and supervision.

INVESTIGATION FINDINGS:

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On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose of delivering findings on a complaint investigation. During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation. Regarding the allegation that a resident eloped from the facility and the caregiver did not know he was gone and that the Facility lacks care and supervision; the following was concluded:
Resident 1 (R1) was admitted to the facility on February 21, 2022. Per physician report dated February 4, 2022, R1 has a diagnosis of Dementia and Delirium with no known history of wander behavior. Prior to moving into Gracious Care Homes, R1 resided with their spouse in their own residence. R1’s spouse indicated they decided to move R1 to facility due to R1’s increase in elopement behavior and safety concerns. R1’s spouse indicated the facility Administrator and facility staff were aware about R1’s elopement behavior prior to moving into the facility. No pre-placement appraisal was observed in R1’s file. R1’s resident care plan dated February 21, 2022, does not note any elopement behaviors.
CONTINUED...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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-20220419091443

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: GRACIOUS CARE HOMES	FACILITY NUMBER: 306003840
	VISIT DATE: 06/22/2023

NARRATIVE

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On March 22, 2022, R1 was sent to the hospital for evaluation. Administrator David Nehem and two of two Caregivers reported R1 was more confused and agitated upon their return to the facility and they would often get up in the middle of the evening screaming and wandering the facility. One of two caregivers reported often advising Administrator David Nehem of these issues and requesting more caregiving assistance and help. Administrator Nehem would occasionally send his son to help during the evening, however, multiple interviews conducted with caregivers and residents revealed that Administrator’s son did not provide much help to alleviate the situation. Interviews with two of two caregivers and two of two residents concluded that facility is understaffed and did not have sufficient number of caregivers to provide services and meet the resident’s needs.
On April 17, 2022, sometime after midnight, R1 exited their rear sliding bedroom door to the backyard, and then exited the side gate to leave the facility. Two caregivers were the only two staff members at the facility at the time and they were both sleeping. There was no alarm on R1’s door to warn staff that they were attempting to leave the bedroom. R1 managed to get approximately two blocks from the facility where they were found by a passerby. R1 was found kneeling in the middle of the street with an injury to the left knee. Passerby drove R1 back to the facility. At the time R1 was not complaining of pain and they were able to walk with their walker. R1 was assessed by staff at the facility and there were no additional injuries observed and R1 was placed back in bed. R1’s responsible party was not contacted nor was medical attention sought at the time. The following morning R1 suffered an unwitnessed fall in their room and was found by caregivers on the floor. Staff called 911 and R1 was transferred to Orange County Global Medical Center (OCGMC).
R1 was admitted to OCGMC under admitting complaint: isolated abdominal trauma-blunt, post unwitnessed fall suffering an intracranial hemorrhage and rib fractures. R1 was later reported deceased on April 30, 2022, at 4:05pm. R1’s death certificate documents the immediate cause of death as Cardiac Arrest and Acute Respiratory Failure with Hypoxia.
Based on the preponderance of evidence gathered through multiple interviews and documents obtained; the allegations “A resident eloped from the facility and the caregiver did not know he was gone” and “Facility lacks care and supervision” have been met; Therefore, the allegations listed above are deemed to be SUBSTANTIATED.
The facility is being cited per Title 22, Division 6 of the California Code of Regulations.
A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f)
An exit interview was conducted with Caregiver Joselene Poy Lorenzo, and a copy of this report, along with LIC9099-D, Appeal Rights,LIC 421IM and the LIC 811, identifying confidential names were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220419091443

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: GRACIOUS CARE HOMES	FACILITY NUMBER: 306003840
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/23/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services-87464(f)(1): Basic Services- Basic Services at a minimum shall include care and supervision. This requirement was not met as evidenced by: On 4/17/2022, the facility did not provide care and supervision for (R1) CONTINUED BELOW...	1 2 3 4 5 6 7	Licensee agrees to provide ongoing assistance to residents who need assistance with their activities of daily living. The assistance shall be provided to ensure that the residents physical health, mental health, safety and welfare are not endangered. CONTINUED BELOW...
	8 9 10 11 12 13 14	...resulting in an elopement with an unwitnessed fall. Staff did not provide supervision resulting in a second unwitnessed fall in R1’s bedroom resulting in hospitalization and fractures. This poses an immediate risk to residents in care. CIVIL PENALITY ASSESSED.	8 9 10 11 12 13 14	This assistance will include providing more staff as needed to meet the needs of all residents.Certification will be provided by the Licensee as proof of understanding of this subsection by POC due date of: 6/23/2023
Type A 06/23/2023 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	Care of Persons with Dementia: 87705(c)(4):Care of Persons with Dementia. There is an adequate number of direct care staff to support each resident’s physical…safety and health care needs… This requirement was not met as evidenced by: Based on CONTINUED BELOW...	1 2 3 4 5 6 7	L/AD Nehem agrees to read and understanding of this subsection and agrees to ensure that all staff follow protocols to meet and support the needs of the residents in care. L/AD Nehem agreed to to review each resident's care plan to...CONTINUE BELOW
	8 9 10 11 12 13 14	interiews, the licensee did not ensure that facility staffing was in adequate numbers to meet R1’s needs resulting in multiple elopement, multiple unwitnessed falls and hospitalization with fractures. This poses an immediate risk to residents in care. CIVIL PENALITY ASSESSED. v	8 9 10 11 12 13 14	ensure that all safety needs are met. L/AD Nehem will conduct in service training about Dementia care and safety to all facility staff. Proof of correction will be provided to CCLD by POC due date of…

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

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