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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004296
Report Date: 04/05/2023
Date Signed: 04/05/2023 11:37:44 AM

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
03/24/2023 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230324163606
FACILITY NAME:PIERCE ADULT RESIDENTAL CARE HOMEFACILITY NUMBER:
306004296
ADMINISTRATOR:ROMMEL MENDOZAFACILITY TYPE:
735
ADDRESS:3112 PIERCE AVENUETELEPHONE:
(714) 556-5102
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 4DATE:
04/05/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jon Castro - AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility failed to seek medical care in a timely manner resulting in serious injury
Facility failed to report the incident to Licensing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to deliver the findings of the investigation. LPA Velazquez was allowed entry into the facility and initially met wih Staff Lordetha Bonilla and explained the purpose of the visit. Administrator Jon Castro arrived later to assist LPA with the visit.

On today's visit LPA Velazquez conducted interviews with clients and staff. LPA also reviewed and obtained copies of facility, client, and staff records. During the course of the investigation the following was revealed: LPA Velazquez conducted interviews with clients and staff. LPA also obtained and reviewed copies of facility, client, and staff records. The records reviewed included Staff Direct Support Professional documents, Client Physician's Reports, and the following records for Client (C) #1: Physician's Report, Individual Program Plan (IPP), Client Development and Evaluation Report (CDER), Regional Center Orange County (RCOC's) Incident Report, HHN Hoag Hospital Newport Beach medical records, and Pelican Ridge Post Acute Skilled Nursing
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
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-20230324163606
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: PIERCE ADULT RESIDENTAL CARE HOME
FACILITY NUMBER: 306004296
VISIT DATE: 04/05/2023
NARRATIVE
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Facility medical records. Six of six individuals interviewed confirmed the facility did not seek medical care in a timely manner for C1. Administrator Jon Castro further confirmed an Incident Report was never submitted to Licensing nor the RCOC when C1 was sent out to the hospital.

C1 was sent out to HHN Hoag Hospital Newport Beach on December 31, 2022 and admitted at 6:23 PM with lethargy and weakness. C1 was intubated and found to have Osteomyelitis of the right foot and Sepsis. C1 underwent surgery requiring a partial amputation of their right foot. C1 remained hospitalized for 9 days and upon discharge from HHN Hoag Hospital Newport Beach was transferred to Pelican Ridge Post Acute Skilled Nursing Facility for further rehabilitation. As of today's date, C1 has not returned to the facility.

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: Facility failed to seek medical care in a timely manner resulting in serious injury and Facility failed to report the incident to Licensing are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 are being cited on the attached LIC 9099D. A Civil Penalty was also issued.

An exit interview was conducted with Administrator Jon Castro and a copy of this report along with the appeal rights, LIC 811, LIC 421IM, and LIC 9098 were provided at the time of this visit. Due to technical issues LPA Velazquez was not able to print the report at the time of the visit and Administrator Jon Castro agreed to receive the report via email.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230324163606
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: PIERCE ADULT RESIDENTAL CARE HOME
FACILITY NUMBER: 306004296
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2023
Section Cited
CCR
80075(a)
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Health Related Services. The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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Licensee to ensure all clients receive needed medical care in a timely manner. Licensee to conduct staff training by 4/14/23 and submit proof of staff training to LPA.
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This requirement is not met as evidenced by: based on interview & record review the licensee failed to obtain medical care for C1 in a timely manner resulting in partial amputation of C1's foot. This poses an immediate risk to the health & safety of clients in care.

CIVIL PENALTY ASSESSED
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Licensee to submit a written statement to LPA indicating they have read this regulation and how they intend to adhere to it by POC due date.
Type B
04/06/2023
Section Cited
CCR
80061(b)(1)(E)
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Reporting Requirements. Upon the occurrence...Events reported shall include the following: Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This
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Licensee to ensure it adheres to this section of Title 22 Regulation at all times. Licensee to submit a written Incident Report to Licensing by POC due date.
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requirement is not met as evidenced by: based on interview & record review the Licensee failed to report C1's incident to Licensing. This poses a potential risk to the health & safety of the clients in care.
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Licensee to submit a written statement to LPA indicating they have read this regulation and how they intend to adhere to it by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3