315002795-5-2-2024-59-AS-TORZ-D4WTUU-20240503150253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002795
Report Date: 05/02/2024
Date Signed: 05/02/2024 03:15:20 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/01/2023 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 59-AS-20230901153423

FACILITY NAME:	A ALWAYS LOVING CARE HOME		FACILITY NUMBER:	315002795
ADMINISTRATOR:	RAI, BALWINDER		FACILITY TYPE:	740
ADDRESS:	1422 ORWELL DR.		TELEPHONE:	(360) 560-1818
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	6	CENSUS: 5	DATE:	05/02/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Balwinder Rai, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff negligence resulted in resident sustaining (2) stage IV pressure injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation. LPA met with Administrator Balwinder Rai during today's inspection.
A complaint investigation was conducted by the Department alleging staff negligence resulted in resident sustaining (2) stage IV pressure injuries. Based on the Department’s investigation, R1 was admitted to the facility May 6, 2023. Upon being admitted to the facility, R1’s physician report, dated 02/14/2022, noted R1 to have a history of skin breakdown. R1 was receiving home health care. R1 required continuous bed care, bowel and bladder impairment, and had a history of skin conditions or breakdown. R1 was noted to be confused/disoriented yet able to follow instructions.
Continuation on 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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 59-AS-20230901153423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: A ALWAYS LOVING CARE HOME	FACILITY NUMBER: 315002795
	VISIT DATE: 05/02/2024

NARRATIVE

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R1 was receiving home health services which was to address and monitor R1’s wounds. On or about 08/14/2023, R1’s home health agency was changed by R1’s responsible party. Progress notes on 08/12/2023, notated R1 primary diagnosis to be an unstageable pressure injury on R1’s right hip and an unstageable pressure injury on R1’s sacral region.

On 08/14/2023, staff were informed by home health during a visit to the facility that R1 had two pressure injuries, as noted during routine assessment, one on the sacrum and one on the right hip. Both pressure injuries were unstageable. Despite the severity of these wounds and the immediate need for medical intervention, staff delayed seeking evaluation by a medical professional, such as a doctor, for approximately 17 days. This delay in obtaining timely medical attention directly contributed to the worsening of the R1’s condition and constitutes negligence on the part of the facility. According to one staff interview, staff failed to adhere to the prescribed turning and repositioning as described during a former staff member’s interview. Through interviews and record reviews, facility did not provide appropriate intervention following the discovery of these injuries, exacerbating the harm suffered by the resident.

On 08/16/2023, Home health nurse reached out to R1’s primary care physician who advised R1 needed to be seen in the Wound Care Clinic. On 8/31/2023, R1 was seen at Wound Care Clinic. It was noted during R1’s Wound Care Clinic appointment that R1 needed a high level of care than what they were receiving at the facility.

Facility staff were interviewed and reported home health nurse would come and change R1’s band aid. Staff indicated home health instructed staff not to touch R1’s pressure wounds or clean them when Home Health was not present. Per home health documentation, Staff were instructed to change R1’s band aid if it was soaked. Staff stated they never changed R1’s band aid. Staff explained that home health would communicate with the Licensee about the pressure injuries. Lastly, based on a staff interview, it was discovered that staff did not receive any training and experience regarding pressure injuries.
Continuation on 9099-C.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230901153423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: A ALWAYS LOVING CARE HOME	FACILITY NUMBER: 315002795
	VISIT DATE: 05/02/2024

NARRATIVE

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According to staff, they acknowledged that R1 had a pressure injury on their back and on the side of their leg. Staff indicated they knew this because they saw a patch on R1. One staff reported that they were not repositioning R1 in August 2023.

Based on records reviewed and interviews conducted it has been determined that the Licensee did not ensure R1 was sent out to hospital after facility staff became aware during a Home Health visit on 8/14/23, that R1 had two pressure injuries one on the sacrum and one on the right hip that were noted as unstageable. R1 was taken to the hospital on 8/31/23 and at that time was also diagnosed with stage four pressure injuries. Given that R1 had been admitted into the facility with a history of skin breakdowns and was being treated for pressure injuries that would warrant medical/physician assessment and involvement at the onset and was not done.

As a result of this investigation, the Department finds the allegation above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. At the time of the complaint visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations Section 87465(g) - Incidental Medical and Dental Care The licensee was informed that a civil penalty was under review and may be assessed at a future date according to Health and Safety Code 1569.49.

Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. Balwinder Rai signature on this report acknowledges receipt of the Appeal Rights.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230901153423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: A ALWAYS LOVING CARE HOME	FACILITY NUMBER: 315002795
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/02/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/03/2024 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465(g) - Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).	1 2 3 4 5 6 7	Administrator agrees to complete training with care staff concerning repositioning, wound care, and contacting emergency services. Copy of the subject of training to be sent into CCL by 5/3/24.
	8 9 10 11 12 13 14	Based on interview and record reviews the licensee did not call emergency services when learning R1 had unstageble wounds which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Once training has been completed with all staff, Administrator to send into CCL and copy of the staff that participated in training.
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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.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC9099 (FAS) - (06/04)

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