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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880546
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:17:16 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200513115313
FACILITY NAME:ESTANCIA DEL SOLFACILITY NUMBER:
331880546
ADMINISTRATOR:NANCY HALLECKFACILITY TYPE:
740
ADDRESS:2489 CALIFORNIA AVETELEPHONE:
(949) 242-1400
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY:135CENSUS: 125DATE:
06/20/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lisa Hunt, Eexcutive DirectorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff withheld information from resident's hospice team.
Facility staff did not follow Resident #1 (R1) treatment plan for administration of oxygen.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegatio(s) listed above. LPA met with Lisa Hunt, Executive Director and explained the purpose and the elements of the allegation(s).

Regarding the allegation Staff withheld information from resident's hospice team
Per documentation reviewed such as Resident #1 (R1) hospice records revealed that on May 7, 2020, at approximately 2100, the Hospice Nurse was called to come out to the facility. The hospice nurse found R1 having “a big change in condition”, R1 was “anxious” and “drooling”. The hospice agency was called but was not told that R1 had been administered air from the nebulizer and not the oxygen concentrator. On May 8, 2020, R1 was visited by a home health Aid, who had come to the facility for regularly scheduled visit to provide Assistance with Daily Living (ADL’s) to R1; R1 would later pass away that day on May 8, 2020. During the interview conducted with hospice Nurse it was denied being informed that R1 was hooked up to the wrong machine. The allegation of Staff withheld information from resident's hospice
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
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-20200513115313
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ESTANCIA DEL SOL
FACILITY NUMBER: 331880546
VISIT DATE: 06/20/2023
NARRATIVE
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team is SUBSTANTIATED.

Allegation: Facility staff did not follow Resident #1 (R1) treatment plan for administration of oxygen.
Interviews and record reviews conducted by the department revealed that on May 7, 2020, R1 was seated at the bar area and observed by Staff #2 (S2) described R1 as “bluish, coughing, choking”. S2 helped R1 back to their room, and informed S1 about R1s condition. S1 responded to R1s room to administer oxygen, which was later confirmed to have been the nebulizer. Staff 3 and 4 were making rounds when they observed that R1 was hooked up to the wrong machine.

S1 admitted that there was a “mix up with the machine”. S1 also stated the mix up was with the “wires” and “the hose”. S1 stated that the “wires” and “the hose” were tangled and that it was the first time attempting to connect R1 up to the oxygen machine and must have switched it. S1 admitted to picking up the nebulizer machine and setting it on the table. “I remember panicking”.

S1 confirmed that they had intended to put R1 on oxygen. S3 and S4 properly connected R1 to the oxygen machine. Hospice was then called to come out to the facility due to R1 having a “change in condition.” Based on interview and records review the allegation is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated.

An exit interview was conducted and a copy of this report, and appeal rights were provided to Lisa Hunt, Executive Director.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200513115313

FACILITY NAME:ESTANCIA DEL SOLFACILITY NUMBER:
331880546
ADMINISTRATOR:NANCY HALLECKFACILITY TYPE:
740
ADDRESS:2489 CALIFORNIA AVETELEPHONE:
(949) 242-1400
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY:135CENSUS: 125DATE:
06/20/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lisa Hunt, Executive DirectorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff neglect contributed to the death of resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation listed above. LPA met with Lisa Hunt and explained the purpose visit and the elements of the allegation.

On May 7, 2020 Resident #1 (R1) was prescribed to use both a nebulizer machine and oxygen concentrator. During dinner R1 was seated at the bar area and observed by Staff #2 (S2) described R1 as “bluish, coughing choking”. S2 helped R1 back to their room, and informed S1 about R1s condition. S1 responded to R1s room to administer oxygen, which was later confirmed to have been the nebulizer. Staff 3 and 4 were making rounds when they observed that R1 was connected to the wrong machine. R1 admitted that there was a “mix up with the machine”. S1 also stated the mix up was with the “wires” and “the hose”. S1 stated that the “wires” and “the hose” were tangled and that it was the first time attempting to connect R1 up to the oxygen machine and must have switched it.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20200513115313
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ESTANCIA DEL SOL
FACILITY NUMBER: 331880546
VISIT DATE: 06/20/2023
NARRATIVE
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S1 admitted to picking up the nebulizer machine and setting it on the table. “I remember panicking”. S1 confirmed that she had intended to put R1 on oxygen. S3 and S4 properly connected R1 to the oxygen machine. Hospice was then called to come out to the facility due to R1 having a “change in condition.” It was also determined that S1 failed to notify facility staff and the hospice agency of the mishap.

S1 has received verbal and written counseling and the facility provided all staff training on the difference between an oxygen and nebulizer treatment. R1 was stable after the hospice nurse made their visit to the facility. Hospice staff noted that R1 was talking and seemed just fine the morning of their passing.

The death certificate classified that the cause of death was “cardiorespiratory arrest with end state Alzheimer’s dementia.” There was nothing noted on the death certificate that the mix up with the nebulizer instead of Oxygen was a contributing factor to R1s death. The allegation of staff neglect contributed to the death of resident is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was provided to Lisa Hunt, Executive Director.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200513115313
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ESTANCIA DEL SOL
FACILITY NUMBER: 331880546
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/04/2023
Section Cited
CCR
87633(4)(a)
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87633 Hospice Care of Terminally Ill Residents (4) A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if...
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The Licensee agrees to conduct an inservice on the facility role vs hospice role when hopsice not at the facility. POC is to be submitted to the department by 5pm on the due date indicated.
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(A) The plan shall specify all procedures to be implemented by the licensee handling of medication, This requirement is not met as evidenced by: 1 out of 1 times the licensee failed to follow the plan This poses a potential health, safety and personal rights risk to persons in care.
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Type B
07/04/2023
Section Cited
CCR
87618(b)(5)
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87618 Oxygen Administration - Gas and Liquid (b).. the licensee shall be responsible for the following: (5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment.This requirement is not met as evidenced by: 1 out of 1 times, that
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The Licensee agrees to conduct an inservice on oxygen administration (O2 and nebulizer). POC is to be submitted to the department by 5pm on the due date indicated.
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licensee did not ensure that staff #1 (S1) knew how to properly operation R1’s oxygen equipment. This poses a potential health, safety and personal rights risk to persons 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5