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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005721
Report Date: 10/05/2021
Date Signed: 10/05/2021 03:35:58 PM



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
06/04/2021 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210604144038
FACILITY NAME:CYECREST GUEST HOMEFACILITY NUMBER:
306005721
ADMINISTRATOR:LUU, CHI VFACILITY TYPE:
740
ADDRESS:139 S LINCOLN STREETTELEPHONE:
(714) 785-9555
CITY:ORANGESTATE: CAZIP CODE:
92866
CAPACITY:6CENSUS: 3DATE:
10/05/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee Tin LeTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained pressure injury while in care.
Staff unable to transfer resident.
Staff did not manage resident's incontinence.
Staff did not assist resident with ADLs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Michelle Reed made an unannounced visit to the facility for the purpose of presenting the findings of the complaint investigation. Upon arrival, LPA met with Staff Harry and Amelia Serra. Administrator Chi Luu was spoken to via telephone. He stated that he was out of state and could not come to the facility. He stated he would contact the Licensee to come to the facility. Tin Le came to facility. The complaint was investigated by the Department and consisted of interviews with the facility staff, Administrator Chi “Rex” Luu, and witnesses as well as documentation. The following was determined:

Resident #1 (R1) moved into Cyecrest Guest Home in March of 2020. R1 had memory impairment but could transfer in and out of bed and walk without assistance. R1 also needed assistance with bathing, toileting and hygiene. At some point during R1’s stay, R1 refused to get out of bed and walk. Family were unable to do in person visits during Covid and during Zoom visits, they noticed that R1 was less active and spending a lot of time in bed. Staff advised family that R1 was doing well, and they were removing R1 from bed and placing R1 in a wheelchair.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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 4
Control Number 22-AS-20210604144038
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: CYECREST GUEST HOME
FACILITY NUMBER: 306005721
VISIT DATE: 10/05/2021
NARRATIVE
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On 4/8/21 Staff #1(S1) left employment at the facility, leaving Staff #2(S2) as the only caregiver. Both staff indicated they were not strong enough to remove R1 from bed on their own and S2 described R1 as bedridden during S1’s absence. This indicated that R1 was not removed from bed from 4/8/21 until R1 left the facility on 5/30/21. S1 also stated that there was usually only one staff member at the facility prior to S1 leaving on 4/8/21.

R1 was removed from the facility on 5/30/21 by family. Family were present during R1’s diaper change. Family observed an open wound on R1’s lower back/buttock area with a foul odor. S2 stated that she had noted a red rash.

R1 did not receive any examination for the pressure injury while in care at the facility. The wound was diagnosed as infected and a Stage III pressure injury by R1’s Primary Care Physician and the Department’s Clinical Consultant’s.

Based upon the Department’s investigation, it is clear that R1 had not been removed/transferred from bed for the time period 4/8/21 through 5/30/21 and possibly longer. As a result, R1 developed a Stage III pressure injury on R1’s coccyx that became infected as evidenced by the foul odor and medical assessment. This is a prohibited health condition that the facility was not approved to care for. In addition, R1’s family was never notified of R1’s wound nor the fact that R1 was completely bedridden, and there was no change of condition documented.

The preponderance of evidence standard has been met and the above allegations are substantiated.

See attached LIC9099D for cited deficiencies per California Code of Regulations, (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report and appeal rights were provided to Licensee Tin Le.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 22-AS-20210604144038
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: CYECREST GUEST HOME
FACILITY NUMBER: 306005721
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2021
Section Cited
CCR
87615(a)
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Prohibited Health Conditions- Persons who have a Stage 3 and 4 pressure injury shall not be admitted or retained in a residential care facility for the elderly.

This requirement was not met as evidenced by:
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Licensee/Administrator agrees to review Prohibited Health Conditions and ensure that residents are not admitted or retained in the facility with such conditions. Proof of understanding of Subsection 87615 will be provided in writing.

Civil penalties were assessed for R1's injury.
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R1 was not removed from bed from 4/8/21 until R1 left the facility on 5/30/21. R1 developed a Stage III pressure injury while in care. R1 was not receiving hospice services. This is an immediate Health and Safety/Personal Rights risk to residents in care.
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Type A
10/06/2021
Section Cited
CCR
87411(a)
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Personnel Requirements-General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met as evidenced by:

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Licensee/Administrator agrees to always have enough staff to meet the needs of resident's in care. Written proof of understanding of Section 87411(a) will be provided.
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R1 was bedridden and Licensee failed to have enough staff to remove him from bed. This is an immediate Health and Safety risk to resident's in care.
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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: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20210604144038
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: CYECREST GUEST HOME
FACILITY NUMBER: 306005721
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2021
Section Cited
CCR
87625(b)(3)(7)
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Managed Incontinence-The licensee shall be responsible for ensuring that incontinent residents are kept clean and dry and the condition of the skin exposed to urine and stool is evaluated regularly to ensure that skin breakdown is not occurring. This requirement was not met as evidenced by:
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Licensee/Administrator agrees to review Section 87625 Managed Incontinence and provide certification that all residents who are incontinent in the facility are checked regularly for skin breakdown. Medical Personnel will be notified immediately for any pressure sores.
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Staff could not move R1 and failed to ensure that R1 was kept clean and dry. R1 developed skin breakdown. This was evidenced by the Infection and foul odor of the Stage III pressure injury. This is a immediate health and safety risk.
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Type A
10/06/2021
Section Cited
CCR
87464(d)
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Basic Services- A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs either directly or through outside resources.
This requirement was not met as evidenced by:
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Licensee/Administrator agrees to meet all resident's needs by hiring more staff as needed. Licensee/Administrator further agrees to notify a resident's family as well as the residents' doctor if a resident requires more care. Certification in writing will be provided.
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R1's ADL's could not be met by staff as staff were limited and R1 was bedridden. The Licensee failed to hire more staff to meet R1's needs and failed to notify R1's doctor and/or outside resources of his wound and bedridden status. R1 was not receiving home health or hospice services. This is an immediate health and safety risk.
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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: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4