306005745-6-2-2022-22-AS-SSAS-CFTTPY-20220628145508

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005745
Report Date: 06/02/2022
Date Signed: 06/02/2022 10:17:08 AM

Unsubstantiated

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
09/23/2021 and conducted by Evaluator Kathrina Chin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210923140440

FACILITY NAME:	IRVINE COTTAGE #5		FACILITY NUMBER:	306005745
ADMINISTRATOR:	WALTERS, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	2 BRANDYWINE		TELEPHONE:	(949) 653-6114
CITY:	IRVINE	STATE: CA	ZIP CODE:	92620
CAPACITY:	6	CENSUS: 5	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Alex Valle, Executive Director		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Allegation 1- The facility failed to provide care and supervision to resident, resulting in death.
Allegation 2 – Resident sustained multiple pressure injuries while in care due to neglect.
Allegation 3- Staff did not address a resident’s change of medical condition.
Allegation 4- Staff did not maintain a resident’s hygiene while in care.
Allegation 5- Staff did not administer medications as prescribed.
Allegation 6- Staff denied resident from visitations.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs), Kathrina Chin and Jessica Cho conducted an unannounced visit for the purpose of delivering the findings on a complaint investigation. LPA Chin and LPA Cho met with Alex Valle, Executive Director and MIchelle Nesbitt, Compliance Manager and were granted entry.

During the investigation of the above allegations, the Department interviewed staff, witnesses as well as reviewed and obtained pertinent records.

The investigation revealed that resident (R1) resided at the Irvine Cottage #5 facility from September 10, 2020 to December 18, 2020. Resident had dementia per the Physician’s Report dated August 4, 2020. Resident was ambulatory and very active when R1 moved into the facility.

(Continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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 4

Control Number 22-AS-20210923140440

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: IRVINE COTTAGE #5	FACILITY NUMBER: 306005745
	VISIT DATE: 06/02/2022

NARRATIVE

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On November 26, 2020, resident was first admitted to hospital #1 (H1) for a gastrointestinal bleeding. Per hospital admission record page 261, the physician noted that there were no skin rash and nothing mentioned about resident having any pressure injuries. On November 29, 2020, resident was discharged from H1 to return to the facility and per medical record, page 254, physician indicated resident’s health was stable and nothing mentioned about having pressure injuries.

On November 30, 2020 to December 3, 2020, the facility staff progress notes documented their observations of resident’s blister to right heel. The resident was referred to a Home Health Agency (HHA) on November 30, 2020. A Nurse Practitioner came to the facility on December 2, 2020, for a follow up visit for the resident. Home health services started on December 4, 2020. HHA records document that the resident was experiencing decline in mental, emotional or behavioral status in the last three months as well as home health admitting diagnosis of muscle weakness, blister on right heel and Alzheimer’s Disease unspecified. Resident was noted to have a Stage 2 pressure injury on coccyx on December 10, 2020 as well as a new pressure injury on the left foot on December 17, 2020. Resident was being seen three times per week by HHA for wound care and physical therapy from December 4, 2020 through December 18, 2020.

Facility Daily Log Records and Monthly Care Plans were obtained and reviewed documenting that resident was diaper changed, repositioned every two to three hours or as needed, transferred into a wheelchair and recliner, and received showers four times a week. Four out of four staff members interviewed stated that resident’s diapers were changed every two to three hours and resident was repositioned every two to three hours every day.

(Continued on LIC 9099C)

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20210923140440

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: IRVINE COTTAGE #5	FACILITY NUMBER: 306005745
	VISIT DATE: 06/02/2022

NARRATIVE

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Based on the information gathered during the investigation and review of all documents obtained, the following allegations: Facility failed to provide care and supervision to resident resulting in death, Resident sustained multiple pressure injuries while in care due to neglect, Staff did not address a resident’s change of medical condition, Staff did not maintain a resident’s hygiene while in care, Staff did not administer medications as prescribed, and Staff denied resident from visitations are deemed Unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted, appeal rights explained and provided. A copy of this report was provided during the visit to Alex Valle, Executive Director.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 22-AS-20210923140440

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: IRVINE COTTAGE #5	FACILITY NUMBER: 306005745
	VISIT DATE: 06/02/2022

NARRATIVE

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While the resident did obtain pressure injuries while in care, resident was being seen and treated by home health for the condition. There is no evidence to show that resident developed stage III pressure ulcers while at the facility. Facility documentation as well as home health documentation indicated that resident was declining with fatigue and poor appetite.

Facility medication records from September 2020 through December 2020 were obtained and reviewed. Resident was taking Levothyroxine, Namenda, Amlodipine Besylate, Lisinopril, Evista, Aricept, Simvastin, Lorazepam, Fish oil, Metamucil, Amox-clan, Vitamin D3, Quetiapine and Senna. Resident’s medications were ordered upon their return from H1 on November 29, 2020. LPA determined facility staff assisted resident with medications according to their physician’s orders. HHA records did not reveal any concerns with implementation of resident’s care plan by the facility staff.

LPA obtained and reviewed facility visitation records documenting their visitation plan for all the residents. The timeframe of no face-to-face visitations or no indoor visitation were during the period of restrictions due to COVID-19. Only outdoor visitations as well as virtual visitations were permitted for family members. The LPA interviewed resident’s responsible parties. Responsible parties corroborated regular virtual visitations and outdoor visitations.

On December 18, 2020, resident was transported to H1 for urinary tract infection without complication and left hip pain. The doctor did not document resident having sepsis UTI. Per H1 records dated January 8, 2021, page 524, the attending Infectious Disease Consultant indicated that there were decubitus ulcers both on the sacral area and bilateral heels. The doctor did not measure the ulcers.

Resident passed away at hospital #2 on February 6, 2021 and the death certificate indicated that resident died from Cardiac Arrest, Acute Respiratory Failure and COVID-19 pneumonia.

(Continued on LIC 9099C)

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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