331800230-2-9-2023-18-AS-EMAN-CP9P9B-20230221100653

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800230
Report Date: 02/09/2023
Date Signed: 02/09/2023 03:22:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
07/13/2020 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200713160712

FACILITY NAME:	CRESENCIA CARE HOME INC		FACILITY NUMBER:	331800230
ADMINISTRATOR:	CALILUNG, RESTITUTO L		FACILITY TYPE:	740
ADDRESS:	1785 HONORS LN		TELEPHONE:	(714) 906-6046
CITY:	CORONA	STATE: CA	ZIP CODE:	92883
CAPACITY:	6	CENSUS: 5	DATE:	02/09/2023
		ANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Restituto Calilung- Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Questionable death.
Staff administered oxygen without a Dr. order.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner scheduled an office visit to deliver findings for the above complaint allegations. LPA met with Administrator Restituto Calilung and explained the reason for the visit.

During today’s visit, LPA conducted interviews with staff, and reviewed, and was provided facility documents.

For allegation, Questionable death:

During document review, LPA discovered that Resident R1 was on hospice and passed away at the facility on June 8, 2020. R1’s death certificate did not have any suspicious concerns. R1’s death certificate listed the cause of death with multiple serious medical conditions.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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-20200713160712

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CRESENCIA CARE HOME INC	FACILITY NUMBER: 331800230
	VISIT DATE: 02/09/2023

NARRATIVE

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During interviews with staff, staff S1 stated that during resident checks on the morning of June 8, 2020, R1 did not look well, and was pale in the face. S1 immediately checked R1’s oxygen level and vitals, and was concerned due to low levels. S1 called the Administrator to inform them that R1 was declining and had a change of condition. The Administrator informed S1 to give R1 oxygen as comfort care per R1’s hospice order for oxygen. S1 immediately called hospice, and hospice informed S1 that they were on the way to the facility. While S1 was calling hospice, the Administrator called R1’s family to inform them of R1’s change of condition. When the hospice nurse arrived at the facility, R1 had already passed, and was officially pronounced deceased upon arrival.

For allegation, Staff administered oxygen without a Dr. order:

During document review, LPA discovered that R1 had a doctor’s order for Oxygen from the hospice doctor dated April 4, 2020. LPA also discovered that the Administrator and S1 had Oxygen Safety Training completed on December 13, 2019, by a Registered Nurse from a hospice company. Additionally, S1 had a second Oxygen Safety Training and Education completed on April 8, 2020.

Based on the evidence gathered during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided Administrator Restituto Calilung, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC9099 (FAS) - (06/04)

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