331800103-3-25-2022-18-AS-NBRN-CDLS43-20220418133204

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800103
Report Date: 03/25/2022
Date Signed: 03/25/2022 05:32:37 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, 1650 SPRUCE ST STE 200 MS29-26
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2019 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20190826165440

FACILITY NAME:	LEGEND GARDENS		FACILITY NUMBER:	331800103
ADMINISTRATOR:	PENDING		FACILITY TYPE:	740
ADDRESS:	73685 CATALINA WAY		TELEPHONE:	(760) 773-3115
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92260
CAPACITY:	96	CENSUS: 0	DATE:	03/25/2022
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Mark Hellickson, former licensee		TIME COMPLETED:	05:31 PM

ALLEGATION(S):

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Resident sustained a heat stroke resulting in hospitalization.
Staff neglect resulted in resident sustaining multiple burns while in care.

INVESTIGATION FINDINGS:

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On 3/25/22, Licensing Program Analyst (LPA) Shaunte Henry delivered the findings to the above allegations via email to former licensee, Mark Hellickson.

The investigation consisted of observation, file review and interviews with relevant parties.

Allegation 1: Resident sustained a heat stroke resulting in hospitalization
The department investigated the allegation that facility staff neglected Resident 1 (R1), which resulted in R1 sustaining a heat stroke. R1 was hospitalized for 28 days. On 8/26/19 and in 108°F weather at approximately 3:00 PM, R1 exited their apartment onto the patio in the facility courtyard. File review indicates R1 was diagnosed with Dementia, was confused and disoriented.
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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Edna Musoke	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

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-20190826165440

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 MS29-26
RIVERSIDE, CA 92507

FACILITY NAME: LEGEND GARDENS	FACILITY NUMBER: 331800103
	VISIT DATE: 03/25/2022

NARRATIVE

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Staff failed to respond to the visual/auditory alarm system when R1 exited their apartment. Seven staff interviews revealed that staff reported that all do not recall the exact time that R1 went outside. All 7 staff confirmed that they did not hear or see the visual/auditory alarm system. S1 found R1 outside at approximately 3:10 PM, sitting on a bench unattended in the patio area, and R1 was unresponsive. R1 was assessed by Staff 1 (S1), 911 was called and R1 was taken to the hospital. R1 was outside approximately 1 hour per staff. Staff reported that R1 was unresponsive and was making snoring like noises and appeared as if they were asleep. R1 was transported to Eisenhower Medical Center with a temperature of 106.1° F. Per hospital records, critical care was necessary to treat or prevent imminent or life-threatening deterioration for central nervous system failure and dehydration. Hospital documents indicates that R1 presented with heat exposure, found unresponsive to (absent pain), flushed and hot reddish skin. Per EMS, R1 had a tympanic temperature of 106.1° F. While in the emergency room R1 developed focal blisters to areas of burn consistent with focal areas of second degree burns to both thighs, chest and abdomen. On 8/30/19, R1 was transferred to the burn unit for the burns which started out as first degree and changed to second degree. While in the burn unit, R1’s status upgraded to 3rd degree burns of bilateral legs and feet (90% of skin below the waist). R1 was discharged from the burn unit and transferred to a skilled nursing facility on 9/23/19.

SUPERVISOR'S NAME: Edna Musoke	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20190826165440

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 MS29-26
RIVERSIDE, CA 92507

FACILITY NAME: LEGEND GARDENS	FACILITY NUMBER: 331800103
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/25/2022 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure residents are regularly observed for changes in physical, mental, emotional... functioning...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee agrees to conduct training to all staff on how provide proper care and supervision to the residents based on their care needs. Proof will be submitted to the Department by 3/25/22.
	8 9 10 11 12 13 14	Based on interviews and file review, on 8/7/19 the licensee failed to ensure proper care and supervision of R1, which led to R1 being hospitialized. (continued in the box to the right)	8 9 10 11 12 13 14	R1 had surgery after sustaining five 3rd degree burns after being left outside in the sun for at least an hour. This poses an immediate health and safety risk to residents in care.
Type A 03/25/2022 Section Cited HSC 1569.269(a)(6)	1 2 3 4 5 6 7	Enumerated Rights;Severability Residential...facilities shall provide care, supervision & services that meets the needs of the residents... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will read and submit statement of understanding regarding Health and Safety Code 1569.269(a)(6). Proof will be submitted to the Department by 3/25/22.
	8 9 10 11 12 13 14	Based on interviews and file review on 8/7/19 the licensee failed to ensure that staff was sufficient in numbers, which resulted in R1 being hospitalized. (Continued in the box to the right)	8 9 10 11 12 13 14	R1 had surgery after sustaining five 3rd degree burns after being left outside in the sun for at least an hour. This poses an immediate health and safety risk to residents in care.

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: Edna Musoke	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20190826165440

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: 03/25/2022

NARRATIVE

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Allegation 2: Staff neglect resulted in resident sustaining multiple burns while in care.
The department investigated the allegation that staff neglect resulted in R1 sustaining multiple burns while in care. On 8/26/19 at approximately 3:00 PM, staff failed to respond to the visual/auditory alarm system when R1 exited their apartment onto the patio in the facility courtyard. File review indicates R1 was diagnosed with Dementia, was confused and disoriented. Seven staff interviews revealed that staff reported that all do not recall the exact time that R1 went outside. All 7 staff confirmed that they did not hear or see the visual/auditory alarm system. S1 found R1 outside at approximately 3:10 PM, sitting on a bench unattended in the patio area, and R1 was unresponsive. R1 was assessed by Staff 1 (S1), 911 was called and R1 was taken to the hospital. R1 was outside approximately 1 hour per staff. On 08/26/19, R1 was admitted to the Eisenhower Medical Center and was diagnosed with a heat stroke/heat exposure. R1 had a temperature of 106.1° F. While in the Emergency Room, R1 developed blisters on the burned areas. The burned areas were consistent with second-degree burns. On 8/30/19 R1 was transferred to UC Irvine Medical & Burn Center with multiple 3rd degree burns. As a result of R1 being exposed to the sun, R1 sustained a 3rd degree burn to the left leg, a 3rd degree burn to the right leg, a deep 3rd degree burn to the left food, a deep 3rd degree burn of the right foot, and a third degree burn to the right thigh. R1 had surgery for these 3rd degree burns. After surgery and treatment for the burns, R1 was discharged to a skilled nursing facility on 9/23/19.

Based on the department’s observations, file review and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6) are being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099D, LIC 811 and appeal rights were provided to former licensee, Mark Hellickson via email.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

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