331800173-12-28-2023-18-AS-JDHS-CZBMDN-20240109083126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800173
Report Date: 12/28/2023
Date Signed: 12/28/2023 09:30:54 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
10/21/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201021110407

FACILITY NAME:	MEGGINSON PLACE II		FACILITY NUMBER:	331800173
ADMINISTRATOR:	RACELIS, JANETTE		FACILITY TYPE:	740
ADDRESS:	11330 LOMBARDY LANE		TELEPHONE:	(951) 363-8767
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY:	6	CENSUS: 5	DATE:	12/28/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Janette Rosario, Administrator		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Staff neglect contributed to death of a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Javina George made an unannounced visit to deliver findings for the allegation noted above. LPA met with Administrator Janette Rosario and explained the purpose of the visit and the elements of the allegation.The investigation consisted of observations, interviews, and records review.
On 10/21/2020, the department received an allegation that staff neglect contributed to the death of a resident. Resident #1 (R1) was admitted to the facility on 07/23/2020. At the time of admission R1 was receiving hospice services. Per a review of R1’s Physician Orders for Life- Sustaining Treatment (POLST) dated 07/23/2020, R1 wanted CPR and full treatment medical interventions. Per a review of R1’s advanced health care directive dated 07/23/2020, it revealed that “All medical personnel to use resuscitation measures to restart or restore the patient’s heart or breathing”. Based on a review of records, text message and notes from the hospice agency, on 08/09/2020, R1 was found by facility staff with a low oxygen level. The text message dated 08/09/2020, revealed the text message was sent from the administrator of the facility to R1’s responsible party.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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 18-AS-20201021110407

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MEGGINSON PLACE II	FACILITY NUMBER: 331800173
	VISIT DATE: 12/28/2023

NARRATIVE

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Text message indicated R1’s oxygen level was “49” and that it was “not good” and that hospice had been called. Per an interview with the administrator, the facility staff called hospice, as well as R1’s responsible party. Based on interview with administrator, facility staff did not provide any treatment other than continuing R1’s oxygen, giving a nebulizer treatment and massaging R1’s extremities. This was corroborated by a review of Facility Daily Care Notes dated 08/09/2020 for R1. Per an interview with the administrator 911 was not called because staff had contacted hospice and staff were waiting to hear back from hospice.

This was refuted by a review of hospice records. Hospice death visit notes dated 08/09/2020 were reviewed. These notes revealed hospice was contacted on 08/09/2020 at 9:41am by the facility administrator. Facility administrator reported R1 had “extremely low oxygenation up to 50%...” The death visit note continues that the hospice nurse had informed the administrator about R1’s code status and that they can call 911. Note further reads, the administrator verbalized understanding. Per the death certificate dated 09/01/2020, the immediate cause of death for R1 was respiratory arrest.

There is sufficient evidence to reveal 911 was not contacted, therefore, the allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means the allegation is valid because the preponderance of the evidence standard has been met.

An immediate civil penalty of $500 is being assessed. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.

An exit interview was conducted where this report, the 9099D, appeal rights and the Civil Penalty assessment form and appeal rights were reviewed with Administrator Janette Rosario.

*** Due to facility staff currently out of vacation and returning at different times, an extension was granted to give ample time to ensure that all staff have been retrained on resuscitative measures. The extension to submit proof of the plan of correction to the department by Friday January 12, 2024.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20201021110407

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MEGGINSON PLACE II	FACILITY NUMBER: 331800173
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 01/12/2024 Section Cited CCR 87469(c)(3)	1 2 3 4 5 6 7	Advanced Directives and Requests Re: Resuscitative Measures If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following: for a terminally ill resident that is receiving hospice	1 2 3 4 5 6 7	in lieu of calling emergency response (911).For emergencies not related to the terminal illness, the facility staff shall immediately call 911. Requirement not met, as the administrator called hospice & hospice advised administrator to call 911. Administrator did not call 911 & R1's cause of
	8 9 10 11 12 13 14	services & has completed an advance directive and/or request re: resuscitative measures form & is experiencing a life-threatening symptoms of impending death that is directly related to the expected course of resident's terminal illness the facility may immediately call resident’s hospice agency	8 9 10 11 12 13 14	death was respiratory arrest.This posed an immediate health, safety and personal rights risk to persons in care. The Licensee agrees to conduct an inservice on resustive measures. Proof of POC is to be submitted to the department by 5pm on 01/12/2024.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC9099 (FAS) - (06/04)

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