306005899-2-7-2023-22-AS-SSAS-CNW3N3-20230209172314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005899
Report Date: 02/07/2023
Date Signed: 02/07/2023 01:32:02 PM

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
07/06/2021 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210706133922

FACILITY NAME:	IN R GREAT HANDS - MONTEVIDEO		FACILITY NUMBER:	306005899
ADMINISTRATOR:	IN, RIZA		FACILITY TYPE:	740
ADDRESS:	1261 MONTEVIDEO AVENUE		TELEPHONE:	(714) 646-9648
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 6	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Denise Molde		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident developed UTI due to lack of care
Resident’s toileting needs are not being met by staff.

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 this complaint investigation. Upon arrival, LPA met with Administrator Denise . Molde. The complaint was investigated and consisted of interviews with the facility Administrators, staff and witnesses. Records were also reviewed. The following was determined:

Resident #1(R1) was admitted into the facility on May 5, 2021. R1 had mild cognitive impairment, incontinence and needed assistance with his ADL’s. R1 ambulated with a walker/wheelchair and was able to communicate his needs. Interviews with staff disclosed that R1’s incontinence had progressed and staff began to double diaper him. Staff #1 told R1 to pee in his diaper when he said he needed to use the bathroom. There was no incontinent plan in R1’s file.

On 6/7/21, according to interviews, R1 began to look thin and pale, was running a fever and would not eat or drink. Staff notified R1’s responsible party to take R1 to the hospital. On 6/14/21 911 was called by

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20210706133922

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: IN R GREAT HANDS - MONTEVIDEO	FACILITY NUMBER: 306005899
	VISIT DATE: 02/07/2023

NARRATIVE

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Administrator Denise Molde and R1 was transported to the hospital with severe sepsis and a urinary tract infection. R1 was placed in skilled nursing and did not return to the facility.

Based upon interviews with staff and witnesses as well as a records review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED.

See LIC9099D for cited deficiencies.

An exit interview was conducted and a copy of this report and appeal rights were provided to Denise Molde.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20210706133922

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: IN R GREAT HANDS - MONTEVIDEO	FACILITY NUMBER: 306005899
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/08/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities- Residents in privately operated residential care facilities for the elderly shall have the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers,qualifications and competency to met	1 2 3 4 5 6 7	Licensee agrees to train staff on the personal rights of residents and ensure that staff assist residents with services that meet their individual needs. Proof of training for staff will be provided via certification by 2/8/23.
	8 9 10 11 12 13 14	and competency to meet their needs. This requirement was not met as evidenced by Staff #1 told R1 to go in his diaper when he needed to use the bathroom. R1 developed a UTI.	8 9 10 11 12 13 14
Type A 02/01/2023 Section Cited CCR 87625(b)(1)	1 2 3 4 5 6 7	Managed Incontinence- the licensee shall be responsible for the following: Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to review Section 87624 Managed Incontinence and ensure that procedures are put into place for incontinent residents upon admission. Certification will be provided of review and understanding by 2/8/23.
	8 9 10 11 12 13 14	Interviews disclosed that Staff #1 double diapered R1 instead of assisting R1 to the bathroom at regular intervals because "he wouldn't make it."	8 9 10 11 12 13 14

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 Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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