331880550-12-27-2023-18-AS-JDHS-CYYNMB-20231229093453

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880550
Report Date: 12/27/2023
Date Signed: 12/27/2023 02:25:16 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 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
09/08/2023 and conducted by Evaluator Kathleen Banrasavong

COMPLAINT CONTROL NUMBER: 18-AS-20230908121201

FACILITY NAME:	PACIFICA SENIOR LIVING PALM SPRINGS		FACILITY NUMBER:	331880550
ADMINISTRATOR:	MELISSA POLENDO		FACILITY TYPE:	740
ADDRESS:	1780 E BARISTO RD		TELEPHONE:	(760) 322-3444
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92262
CAPACITY:	95	CENSUS: 63	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Executive Director, Tammy Eddy		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff do not ensure a safe and healthful environment by not assisting a resident with incontinence needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver finings for a complaint investigation pertaining to the listed allegation. LPA met with Executive Director, Tammy Eddy, where LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observation, interviews with staff members and residents, and records review.
On 09/08/2023, Community Care Licensing received a complaint alleging that Staff do not ensure a safe and healthful environment by not assisting a resident with incontinence needs. It was reported that Resident #1 (R1)’s were not attended to for over 20 hours on September 8th, 2023. Information obtained from additional witness stated that on September 8th, in the late afternoon, additional witness, came to visit R1 and their bedding and chucks were soaked. Additional witness stated it was unknown liquid, which may have consisted of urine or seepage from the water blister wound that R1 had. LPA received photographs of the bedding being soaked.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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-20230908121201

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING PALM SPRINGS	FACILITY NUMBER: 331880550
	VISIT DATE: 12/27/2023

NARRATIVE

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Resident Care Manager, Patrica Russell addressed the additional witness’ concerns and in conjunction with additional witness, revised R1’s care plan. The care plan ensured that R1 would be checked on every hour and changed if needed. LPA reviewed records from the facility, in which additional witness requested facility staff implement every shift. LPA also reviewed documentation from the revised care plan and requested information regarding the communication between the facility and the hospice nurse. The information stated that there was a request in changing chucks due to excessive weeping from the wounds. LPA interviewed residents who stated that there were no issues with asking for assistance with an assistance in daily livings, which include incontinence matters. LPA interview staff, who indicated that they followed the new directive plan given to do rounds every two hours and after the revision of the care plan, increased checks on R1 every hour. Resident Care Director, Patrica Russell stated that the facility has been implementing the new procedures after the concerns were addressed to Resident Care Director.

Based on LPAs observations and interviews which were conducted and record review(s), in regards to the allegation of staff do not ensure a safe and healthful environment by not assisting a resident with incontinence needs, the preponderance of evidence standard has been met. Therefore, the above allegation(s) is found to be SUBSTANTIATED. This poses a health and safety and or personal rights risks to residents in care. California Code of Regulations, (Title 22, Division 6 Chapter 8 Article 11. Health-Related Services and Conditions, 87625 (b)(3) ), are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20230908121201

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING PALM SPRINGS	FACILITY NUMBER: 331880550
	VISIT DATE: 12/27/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	An exit interview was conducted. A copy of this report, LIC 9099-D, and appeal rights were discussed with and provided to the Executive Director, Tammy Eddy.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20230908121201

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING PALM SPRINGS	FACILITY NUMBER: 331880550
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/27/2023 Section Cited HSC 87625(b)(3)	1 2 3 4 5 6 7	87625 (b) (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Executive Director, Tammy Eddy stated that she will provide training and acknowledgement of staff training of the regulation and signature to the LPA by 01/10/2023.
	8 9 10 11 12 13 14	Based on LPA's record review, interviews, R1 was not accorded their right to be kept clean and dry, R1’s room was not free from odors from the Purewick machine.	8 9 10 11 12 13 14
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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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

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