331800103-10-21-2021-18-AS-DMUN-CAE35Y-20220105165730

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800103
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:04:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/29/2020 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201229155629

FACILITY NAME:	LEGEND GARDENS		FACILITY NUMBER:	331800103
ADMINISTRATOR:	YNDIRA LEPE		FACILITY TYPE:	740
ADDRESS:	73685 CATALINA WAY		TELEPHONE:	(760) 773-3115
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92260
CAPACITY:	96	CENSUS: 29	DATE:	10/21/2021
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Mirlan Lopez, Lead Med Tech		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Licensee did not follow physician's orders
Temperature at facility is not maintained within the required range
Licensee did not provide resident access to telephones
Licensee did not provide responsible party written notice prior to rate increase
Licensee did not provide resident's medical information to medical provider
Licensee did not inform resident's representative of activities related to resident's care
Facility retaliating against resident due to reporting party filing a complaint
Caregiver did not follow universal precaution while assisting resident with medical equipment

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude a complaint investigation into the allegations list above. LPA met with Lead Med Tech Mirlan Lopez and explained the purpose of the visit. Community Relations Director Carrie MacDonald was out of the facility during LPA's visit.
Regarding the allegation "Licensee did not follow physician's orders", it was alleged that the facility did not follow doctor's orders in obtaining a flu shot for Resident #1 (R1), nor did the facility ensure medical equipment was utilized as ordered for R1 and finally, R1 was not provided oxygen as ordered. The investigation revealed no evidence of a physician's order for the medical equipment in question nor was any evidence discovered that an order for a flu shot was written for R1. Records reviewed also revealed R1 was not prescribed oxygen until 4/20/2021. Interview with med tech staff revealed there were no flu shots obtained for any resident in the year 2020 due to COVID-19 restrictions.
Regarding the allegation "temperature at facility is not maintained within the required range", it was alleged that the facility is too cold in R1's room. LPA observed the thermostat in R1's room to be set at 83 degrees Fahrenheit and the ambient room temperature was measured at 83.4 degrees Fahrenheit. (CONTINUED ON LIC 9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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 18-AS-20201229155629

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LEGEND GARDENS	FACILITY NUMBER: 331800103
	VISIT DATE: 10/21/2021

NARRATIVE

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(CONTINUED FROM LIC9099)
During LPA interview with R1, R1 stated they are always cold no matter the temperature due to their medical condition. LPA observed R1 to be covered with two (2) blankets at the time of LPA visit to R1's room when the room temperature was 83.4 degrees Fahrenheit. LPA measured air temperatures in various areas of the memory care unit on 5/19/2021. Temperatures measured 77.5, 81.3, 79.8, 79.1, 74.1, 74.3, 76.2, 77.3, 75.5, and 79.1 degrees Fahrenheit and all within regulatory requirements.
Regarding the allegation "Licensee did not provide resident access to telephones", it was alleged that the facility would not allow R1 to utilize the phone to make or receive calls. During LPA interview with R1, R1 reported no issue with being allowed to utilize the phone. During LPA visit on 5/19/2021, LPA observed R1 using the facility phone for a long and engaging conversation. LPA interviews with memory care staff revealed that at times, the phone may go unanswered if all staff are engaged with a resident and are unable to leave the resident to answer the phone, but that all calls are returned if a message is left. Per interview with Interim Administrator Damion Anderson, the facility employs an answering service for all incoming calls so that no calls are missed however, all facility phones have the ability to call out at anytime. Per interview with Lead Med Tech Mirlan Lopez, all messages from the answering service are forwarded to the facility cell phone which is maintained and monitored by the Lead Med Tech on duty. Per Lopez, the messages are then conveyed to the appropriate parties and/or calls are returned.
Regarding the allegation "Licensee did not provide responsible party written notice prior to rate increase", it was alleged that the monthly rate for R1's residency at the facility was unlawfully increased in October 2019. Records reviewed by LPA revealed a letter dated October 31, 2019 was sent to R1's responsible party to provide notification that the monthly rate for R1 would increase 5% to $4,641 from $4,420 per month beginning January 1, 2020. Records reviewed by LPA revealed a letter dated July 8, 2020 was sent to R1's responsible party requesting past due payments in the amount of $21,002 for months on April 2020, May 2020, June 2020, and July 2020. The July 8, 2020 letter also revealed R1's responsible party was once again reminded of the new monthly rate of $4,641 which had taken effect on January 1, 2020. Also revealed during record review, LPA discovered a letter dated August 25, 2020 from the facility's legal representation, Blumberg Law Group sent First Class Mail as well as to R1's responsible party's email address attempting to collect on R1's delinquent account. Blumberg's letter demanded payment of $25,643 for R1's past due rent. It also reiterated the dates notices were sent pertaining to R1's rent increases in 2019 and 2020. LPA's investigation also revealed R1's responsible party was sent a monthly statement on September 1, 2020 indicating a balance of $30,284. The statement also delineated the monthly rate increase which took effect January 1, 2020. (CONTINUED ON LIC 9099 C)

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20201229155629

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LEGEND GARDENS	FACILITY NUMBER: 331800103
	VISIT DATE: 10/21/2021

NARRATIVE

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(CONTINUED FROM LIC 9099C)
Regarding the allegation "Licensee did not provide resident's medical information to medical provider", it was alleged that during R1's hospitalization in late 2020, the facility failed to notify the hospital R1 was taking Seroquel and therefore was not given Seroquel during their hospitalization. It should be noted that during LPA's interview with the Reporting Party (RP), RP stated, "I don't know who dropped the ball on that; I don't know if it was the skilled nursing facility's fault on that". During LPA interview with facility med tech staff, it was discovered that R1's Medication Administration Records (MARs) were provided to the ambulance transport services staff to be transported along with R1 to Eisenhower Medical Center (EMC) and that R1 was further transferred by EMC to a skilled nursing facility for long term recovery. Records reviewed revealed R1 was prescribed twenty (20) different medications at the time of their transport to EMC yet there are no indications or complaints that R1's other medications were not provided while hospitalized. Records reviewed revealed no evidence that the facility failed to notify EMC of R1's medications.
Regarding the allegation "Licensee did not inform resident's representative of activities related to resident's care", it was alleged that the former facility Administrator (AD) and former Chief Operating Officer (COO) refused to discuss issues related to R1 with R1's responsible party. It should be noted that during LPA's interview with the Reporting Party (RP), RP denied having ever made this allegation and that it was not accurate. During LPA record review, LPA observed a very long chain of emails between R1's repsonsible party and facility COO where various issues were discussed. LPA interviews with AD and COO revealed no evidence that R1's responsible party was refused conversations to discuss R1's care.
Regarding the allegation, "Facility retaliating against resident due to reporting party filing a complaint", it was alleged that R1 had complained to unidentified staff about various issues at the facility and had been told "if you don't like it you can leave" rather than assist R1 with the issues they had complained about. Interview with R1 revealed no complaints about living at the facility and they stated, "I'm safe here and Legend takes good care of us". Interviews with five (5) of five (5) memory care staff revealed R1 had not expressed any complaints about their residency at the facility nor did any staff interviewed report ever making a statement of that nature to R1.
Regarding the allegation "Caregiver did not follow universal precaution while assisting resident with medical equipment", it was alleged that Staff #1 (S1) was not wearing gloves when applying medical equipment to R1's leg and as a result, R1's leg was punctured by S1's fingernails. Interview with S1 revealed S1 was wearing double gloves during the incident in question due to the oozing from a medical condition on R1's leg. During LPA interview with R1, R1 reported staff are careful to always wear gloves when assisting them with
(CONTINUED FROM LIC 9099C)

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20201229155629

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LEGEND GARDENS	FACILITY NUMBER: 331800103
	VISIT DATE: 10/21/2021

NARRATIVE

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(CONTINUED FROM LIC 9099C)
their medical equipment and R1 further reported they do not enjoy wearing the medical equipment in question because it is not comfortable. R1 further stated, "The staff here are trained well" and denied that S1 or any other staff had ever caused injury to their legs during assistance with their medical equipment. Records reviewed also revealed there is no physician's order for the medical equipment in question. Interviews with facility staff indicated that R1's responsible party wants it used however, there is no actual direction from a physician to do so.
This agency has investigated the complaint alleging "Licensee did not follow physician's orders", "Temperature at facility is not maintained within the required range", "Licensee did not provide resident access to telephones", "Licensee did not provide responsible party written notice prior to rate increase", "Licensee did not provide resident's medical information to medical provider", "Licensee did not inform resident's representative of activities related to resident's care", "Facility retaliating against resident due to reporting party filing a complaint", and "Caregiver did not follow universal precaution while assisting resident with medical equipment". We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC9099 (FAS) - (06/04)

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