306004598-2-7-2022-22-AS-LADS-CD9NXR-20220407105135

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004598
Report Date: 02/07/2022
Date Signed: 02/07/2022 11:48:42 AM

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
09/28/2020 and conducted by Evaluator Albert Marin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200928155730

FACILITY NAME:	DELIGHTFUL LIVING		FACILITY NUMBER:	306004598
ADMINISTRATOR:	REBEKAH BUBOI		FACILITY TYPE:	740
ADDRESS:	26811 CARMENITA LANE		TELEPHONE:	(714) 600-5845
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	02/07/2022
		UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Administrator Rebekah Buboi		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Due to neglect, resident sustained skin breakdown while in care.
Resident's tubing and bandages had not been changed for an extended period of time

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility. LPA was granted entry after completed the Coronavirus 2019 (COVID 19) screening procedures. LPA met with Administrator Rebekah Buboi and stated the purpose of this visit. The purpose of this visit was to deliver the findings for the investigation of the complaint received last September 28, 2020 against this facility.

On allegation that due to neglect, resident sustained skin breakdown while in care, the following are the findings. Resident 1 (R1) had been in the facility since December 19, 2016. Per physician’s report dated December 19, 2016, R1 had primary diagnosis of multiple sclerosis. R1 had bowel, bladder and motor impairment; and with limited capacity for self-care. R1 underwent multiple medical and surgical procedures to address urinary function needs. To address R1’s medical needs, a home health agency managed R1’s case from February 18, 2018 until February 8, 2021. Home health staff regularly check the resident and reported that R1 had on and off injuries ranging from Stage 1 to Stage 2. As defined in Cleveland Clinic website, Stage 1 is discolored skin. The skin appears red in those with lighter tones and blue/purple in those with darker skin tones. The skin does not blanch (turn white) when pressed with a finger. (continuation on page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

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 2

Control Number 22-AS-20200928155730

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: DELIGHTFUL LIVING	FACILITY NUMBER: 306004598
	VISIT DATE: 02/07/2022

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
26
27
28
29
30
31
32

Stage 2 involves superficial damage of the skin. The top layer of skin is lost. It may also look like a blister. At this stage, the top layer of the skin can repair itself. Per file review of facility communication log, facility was in regular communication with home health in reference to the skin issue of R1.Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the above allegation is deemed UNSUBSTANTIATED

On allegation that resident's tubing and bandages had not been changed for an extended period of time, the following were the findings. Resident 1 (R1) had been in the facility since December 19, 2016. In August 25, 2020 R1 underwent a right kidney tube insertion. After discharge, R1 was managed by a home health agency which had R1 under care since February 18, 2018. Home health nurse was in charge of following up the status and care of kidney tube. Per interviews, care staff were trained what to observed for and when to refer to the home health. Home health visits to address the insertion site care were documented. Thus, the allegation is UNSUBSTANTIATED.

LPA Marin conducted an exit interview with AD R. Buboi and copies of this report was left in the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2