306004186-12-5-2023-22-AS-SSAS-CYBPDP-20231208101352

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004186
Report Date: 12/05/2023
Date Signed: 12/05/2023 03:27:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/19/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230519142410

FACILITY NAME:	HORIZON LEGACY ELDERLY CARE HOME		FACILITY NUMBER:	306004186
ADMINISTRATOR:	PEDROZA, JOHN		FACILITY TYPE:	740
ADDRESS:	25351 DIANA CIRCLE		TELEPHONE:	(949) 859-1217
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS:	DATE:	12/05/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:			TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident developed stage 4 pressure injuries due to neglect from facility staff

Resident developed sepsis while in care

Resident is malnourished due to staff neglect

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the allegation listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Administrator Flor Pedroza was notified of the visit and arrived later to assist. The allegation investigated were presented to the administrator.

An initial complaint investigation visit was conducted by LPA Saborit-Guasch on May 22, 2023. The complaint was investigated by the Department and consisted of a review of staff and residents’ records, a physical plant inspection and interviews of staff, witnesses and residents. An additional review of hospital and Home Health records obtained from Hoag Health was conducted later in addition to staff and witness interviews.

CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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-20230519142410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HORIZON LEGACY ELDERLY CARE HOME	FACILITY NUMBER: 306004186
	VISIT DATE: 12/05/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099
Resident R1 was admitted to the facility on March 4, 2023, after being discharged from Skilled Nursing. Home Health services were put into place at the time of admission and Home Health records were obtained and reviewed during the investigation. On March 6, 2023, Home Health records indicate that the pressure injuries treated on R1 were staged at a stage 2. Records indicate that Home Health staff provided R1 with wound care and wound assessments two to three times a week until R1 was admitted to the hospital on May 17, 2023. Records show pressure injuries continuing to be assessed as stage 2 until May 5, 2023. At that date, Home Health records state one of the pressure injuries treated evolved to a stage 3, but none were ever assessed beyond that stage.

Regarding the allegation that Resident developed sepsis due to neglect from facility staff, the following has been concluded: Prior to admission at Horizon Legacy Elderly Care Home (the facility), Resident R1 was a patient in a skilled nursing facility recovering from a surgery. R1 was admitted to the facility with pressure injuries preset on both heels and his coccyx, according to interviews conducted with staff and witnesses. R1 was admitted to the facility with additional care provided by Hoag Home Health nursing staff. Home Health supervised wound care for R1’s pressure injuries among other health issues. Home Health Nurses visited R1 at the facility almost every other day to perform wound care, check his vitals and overall health. Hoag Home Health nursing staff was under the supervision of W1, Nurse Practitioner for Hoag. During this time, R1 was also under the care of Registered Nurse (RN) W2 who was hired and paid for separately by R1’s family.
Based on an interview with W2, R1’s pressure injuries were healing prior to him be transported to Hoag Hospital on May 17, 2023, but they were healing slowly due to R1 recovering from surgery. W2 stated the facility provided adequate care and supervision to R1. W2 denies observing neglectful treatment by facility staff. W1 confirmed the statements on the rate of recovery from the pressure injuries present on admission and added that caloric malnutrition was also a factor. W1 also denied observing any neglectful treatment of R1.

During R1’s stay at the facility, there is ample evidence of active treatment for his pressure injuries being dispensed by qualified medical staff and his wounds were in the process of healing prior to be transported to Hoag Hospital on May 17, 2023. Based on interviews conducted and records reviewed, the allegation that Resident developed stage 4 pressure injuries due to neglect from facility staff is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. CONTINUED ON FORM LIC9099-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230519142410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HORIZON LEGACY ELDERLY CARE HOME	FACILITY NUMBER: 306004186
	VISIT DATE: 12/05/2023

NARRATIVE

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CONTINUED FROM LIC9099-C
Regarding the allegation that Resident developed sepsis due to neglect from facility staff, the following has been concluded: Based on a review of R1’s physician report and medical records, R1 had a history of urinary tract infections and sepsis due to the use of a Catheter and is stated to have developed a resistance to many antibiotics.
R1 was admitted to the facility with additional care provided by Hoag Home Health nursing staff under the supervision of W1, Nurse Practitioner for Hoag in addition to Registered Nurse (RN) W2 who was hired and paid for separately by R1’s family. Approximately one week before R1 was sent to Hoag Hospital to be evaluated on May 17, 2023, facility staff noticed R1’s urine was dark and had a foul odor. After testing, it was determined Lonnie had a UTI. W1 prescribed Amoxicillin Antibiotics for R1’s condition with no noticeable results. W1 then prescribed a different antibiotic for R1, who ended up transferring to Hoag Hospital before the new antibiotic was delivered at the facility.
Medical professionals assigned to R1’s care while at the facility were actively treating his chronic conditions. When it was determined the treatment/medication was not effective, he was sent to the hospital for further evaluation and treatment as required by Title 22 regulations.
Based on records reviewed and interviews conducted, the allegation that Resident developed sepsis due to neglect from facility staff is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Regarding the allegation that Resident is malnourished due to staff neglect, the following has been concluded: Based on records reviewed and interviews conducted with staff and witnesses, there is no evidence that facility staff failed to provide adequate nutrition to resident R1 based on his individual needs. Evidence of caloric malnutrition were apparent in the slow rate of healing of R1’s pressure injuries and in testimony made by W1, however the investigation could not corroborate that the caloric malnutrition described was not a result of the resident’s pre-existing conditions documented in the records reviewed. At the time of his discharge from Skilled Nursing, R1 was documented as having the following diagnosis: Metabolic Encephalopathy, Pseudomonas Urinary Tract Infection, Muscle Weakness, Unspecified Atrial Fibrillation, Hypertension, Malignant neoplasm of lower and middle lobe, presence of a prosthetic heart valve as well as a pre-existing instance of sepsis. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC9099 (FAS) - (06/04)

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