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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800103
Report Date: 02/04/2022
Date Signed: 02/04/2022 05:10:55 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
02/08/2021 and conducted by Evaluator Tricia Danielson
COMPLAINT CONTROL NUMBER: 18-AS-20210208164107
FACILITY NAME:LEGEND GARDENSFACILITY NUMBER:
331800103
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:73685 CATALINA WAYTELEPHONE:
(760) 773-3115
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:96CENSUS: DATE:
02/04/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Staff and Designee unavailable, facility closed 1/6/2022TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not ensure resident was seen by a physician
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson phoned designee Mark Hellickson in an effort to deliver findings of an investigation into the allegation listed above. LPA was unable to make contact with Hellickson and although LPA requested a return call, one was not received. Regarding the allegation "Staff did not ensure resident was seen by a physician", it was alleged that Resident #1 (R1) was not seen by a physician following a fall at the facility. The investigation revealed R1 experienced a fall on 01/27/21 at about 2230 hours while in their room. R1 was found on the floor in their room and was assessed by facility staff. R1 was found to have stable vital signs and refused to go to the hospital due to lack of pain/discomfort. Staff interviewed stated R1 is high functioning and able to communicate their needs or express pain. Staff interviewed also reported R1's doctor was not notified of the fall. On 02/06/21, staff observed R1 to have a change of condition as exhibited by a visibly pale face, lack of appetite, and decreased interaction. Staff notified emergency services and R1 was transported to Eisenhower Medical Center where they were diagnosed with fractured ribs. Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, is being cited on the (CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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 5
Control Number 18-AS-20210208164107
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2021
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care-(a) A plan for...medical care shall be developed by each facility. The plan shall ...provide for assistance in obtaining such care, by...following:(1)The licensee shall arrange, or assist in arranging...medical care...appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Designee was not available for plan of correction. Facility was closed January 6, 2022
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The licensee did not ensure R1 was seen by a physician following a fall on 1/27/21. Based on interviews which were conducted, facility staff stated R1 was not seen by a physician until 2/6/21. This poses a potential health, safety, and personal rights risk to residents 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: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20210208164107
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: 02/04/2022
NARRATIVE
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(CONTINUED FROM LIC 9099)
attached LIC 9099D.
An exit interview was not able to be conducted however, a copy of this report along with LIC 811- Confidential Names List was sent via email at m.hellickson@icloud.com.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/08/2021 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210208164107

FACILITY NAME:LEGEND GARDENSFACILITY NUMBER:
331800103
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:73685 CATALINA WAYTELEPHONE:
(760) 773-3115
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:96CENSUS: DATE:
02/04/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Staff and designee not available, facility closed 1/6/2022TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident fell multiple times sustaining fractures
Resident is being over medicated
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson phoned designee Mark Hellickson in an effort to deliver findings of an investigation into the allegation listed above. LPA was unable to make contact with Hellickson and although LPA requested a return call, one was not received. Regarding the allegation "Resident fell multiple times sustaining fractures", it was alleged that the facility neglected R1 and failed to provide adequate supervision which resulted in R1 sustaining multiple rib fractures. The investigation revealed R1 fell while in their room on 01/27/21 during shift change at about 2230 hours. Staff heard R1 call for help and staff then found R1 on the floor of their room. Staff did not observe any visible marks, bruises or lacerations during their assessment of R1 who also verbalized they were not in pain. R1 was later seen at Eisenhower Medical Center (EMC) where it was discovered R1 had fractured ribs. EMC personnel were unable to determine how old the fractures were therefore, although R1 sustained a fall in their room which resulted in fractured ribs, it was an accidental fall which R1 stated they felt dizzy and had lost their balance. Regarding the allegation "resident is being over medicated", it was alleged that R1 loses their balance and sounds "drugged" when spoken to. Interview with Eisenhower Medical Center (EMC) staff revealed R1's medical conditions are known
(CONTINUED ON LIC 9099 - C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20210208164107
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: 02/04/2022
NARRATIVE
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(CONTINUED FROM LIC 9099-A)
factors to contribute to falls. EMC staff also noted that one specific medication of R1 will cause sedation for a while after it's consumption. Interview with R1's responsible party also revealed that R1 appears and sounds confused when they are becoming sick. During LPA interview with R1 on 5/19/2021, LPA did not observe R1 to be unsteady on their feet, have slurred speech, or to be drowsy. R1 reported they can be unsteady at times due to their medical condition and can become dizzy when rising from a chair or bed too quickly. There is no evidence that the facility was providing more than the prescribed amount of medication for R1. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was not able to be conducted however, a copy of this report along with LIC 811- Confidential Names List was sent via email at m.hellickson@icloud.com.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5