306004555-4-15-2021-22-AS-JAUT-C24TWJ-20210415150534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004555
Report Date: 04/15/2021
Date Signed: 04/15/2021 03:05:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	CAPRIANA		FACILITY NUMBER:	306004555
ADMINISTRATOR:	TONYA REYNOLDS		FACILITY TYPE:	741
ADDRESS:	460 LA FLORESTA DR		TELEPHONE:	(714) 589-2866
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	200	CENSUS: 114	DATE:	04/15/2021
TYPE OF VISIT:	Case Management - Deficiencies	ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Licensee Sue McPherson and Administrator Tonya Reynolds		TIME COMPLETED:	10:59 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A virtual office meeting was held April 15, 2021 and present during the meeting are Executive Director Tonya Reynolds, Licensee Sue McPherson, Acting Regional Manager Marina Stanic, Licensing Program Manager Sheila Santos and Licensing Program Analyst Jim August. On January 17, 2018, the Department concluded a complaint investigation which alleged the following: the facility failed to dial 9-1-1 emergency personnel for a Resident (R1) during a choking incident, the facility lost R1's personal belongings, the facility failed to meet R1's dietary needs, and facility staff are incompetent and are not properly trained. On January 17, 2018, the Department concluded that the complaint investigation and all allegations were substantiated. The licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87466 Observation of the Resident for failure to ensure that the Resident's diet was changed to a softer diet and failure to identify R1 as a choking risk. The licensee was also cited for CCR Tittle 22, § 87465(g) Incidental Medical Dental Care for failure to call 9-1-1 to obtain emergency assistance when R1 was observed by facility staff to be choking on meat. The licensee was also cited for CCR Title 22, §87411(a) Personnel Requirements – General for failure to follow the facilities policies regarding providing CPR until emergency assistance arrived. The licensee was also cited for CCR Tittle 22, § 87218(a)(2) Theft and Loss for failure to safeguard R1 dentures as required. The investigation revealed that on or about July 12, 2017, R1's responsible party observed that R1's lower dentures were missing. The Responsible party informed staff #1 (S1) by email on July 12, 2017 and requested a soft diet be provided to R1. S1 did not inform any staff nor R1's physician. Continued on LIC809C Dated April 15, 2021...

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CAPRIANA	FACILITY NUMBER: 306004555
	VISIT DATE: 04/15/2021

NARRATIVE

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On August 3, 2017, R1 was eating a meal, which consisted of steak in the dining room served by Staff #5 (S5), when staff witnessed R1 in distress. R1 subsequently choked on a piece of steak and passed away at the facility. Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4), all of whom are Licensed Vocational Nurses (LVN), witnessed the incident with R1, however failed to call 9-1-1 or continue Cardio Pulmonary Resuscitation (CPR) per facility protocol but instead took R1 to R1’s room where R1 continued to choke and subsequently died. Both S2 and S3 stated that R1 was brought to R1 room to keep the other residents from being scared. Both S2 and S3 also stated that the Heimlich maneuver (abdominal thrusts – first aid procedure) was discontinued once R1 was transported R1 room because R1 was on Do Not Resuscitate (DNR) status, however the DNR order was for a heart condition and renal failure not choking. According to the report the Brea Police Department dated August 3, 2017, staff did not call 9-1-1 emergency personnel because R1 was on hospice (unrelated to choking) and had a Do-Not-Resuscitate (DNR) order.

During an interview S1 stated that 9-1-1 was not called due to the R1 being on hospice and having a current DNR order, however facility staff contacted the Hospice agency instead after R1 had passed away. The nurse (S6) from the hospice care agency, arrived at the facility two hours later, but then S6 contacted Brea Law Enforcement because the hospice care agency could not announce the time of death. S6 stated they could not put a time of death due to the resident dying of choking instead of heart and renal disease which was the hospice condition. According hospice records, the hospice care agency was not notified that R1 was at risk for choking.

An autopsy was conducted on August 4, 2017, and the manner of death was determined to be caused by choking. R1’s death certificate indicates that R1 ''choked on Food Bolus."
Based on observation, interview, and record review, the licensee failed to meet R1’s dietary needs that caused R1 to choke on R1’s food that resulted in R1’s death. The licensee also failed to safeguard R1’s dentures, failed to give CPR to R1, and failed to call 9-1-1 during and after R1 choked on R1’s food.

At the time of the visit conducted on January 17, 2018, a civil penalty was still being determined based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that an additional civil penalty is warranted for violation determined to have resulted in the death of a resident.

Continued on LIC809C Dated April 15, 2021...

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CAPRIANA	FACILITY NUMBER: 306004555
	VISIT DATE: 04/15/2021

NARRATIVE

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Today, April 15, 2021, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 in the amount of $15,000 for a violation determined to have resulted in the death of a resident. A copy of the LIC 421D was given to Executive Director/Licensee representative Tonya Reynolds and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Licensee representative Tonya Reynolds signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC809 (FAS) - (06/04)

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