331880572-8-16-2021-18-AS-JESL-C7CT9H-20210930143158

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880572
Report Date: 08/16/2021
Date Signed: 08/16/2021 10:43:49 AM

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 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200602114358

FACILITY NAME:	PACIFIC VISTA SENIOR LIVING		FACILITY NUMBER:	331880572
ADMINISTRATOR:	TENG, JAMIE		FACILITY TYPE:	740
ADDRESS:	17085 BIRCH HILL ROAD		TELEPHONE:	(951) 850-1088
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	6	CENSUS: 5	DATE:	08/16/2021
		UNANNOUNCED	TIME BEGAN:	10:16 AM
MET WITH:	Luisa Agnote-Caregiver		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility failed to observe resident's change in condition.
Facility did not obtain timely medical treatment for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George arrived unannounced at the facility to deliver findings for the allegation(s) listed above. LPA met with Caregiver Luisa Agnote and explained the purpose of the visit as well as the elements of the allegations. Administrator Jamie Teng was unavailable The allegation was investigated by the department. The investigation consisted of observation and interviews.

Allegation: Facility failed to observe resident's change in condition.
Resident #1 (R1) was receiving hospice services began on October 1, 2019. It was noted in the case notes on March 6, 2020 that there was a change with R1’s big toe. The notes revealed that the toe was red and swollen, tender to touch, began to change colors; purple then black in some areas, prompting for a referral being made to the Podiatrist. R1 was seen on March 30, 2020, by the podiatrist where R1 was diagnosed with vascular (circulation) insufficiency, and not gangrene, surgery was recommended. However, per R1s POA, whom confirmed that they were informed of the change in R1s condition, also stated that R1 declined to have the surgery after being educated on the risks associated without having the surgery, as well as the benefits of having the surgery. Members of R1s treatment team did have knowledge of the change in condition and followed the recommendation from the hospice nurse to see the podiatrist.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021

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-20200602114358

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: PACIFIC VISTA SENIOR LIVING	FACILITY NUMBER: 331880572
	VISIT DATE: 08/16/2021

NARRATIVE

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Additionally, a subsequent referral was made for R1 to see the Podiatrist, however per the Podiatrist letter dated May 20, 2020, without the surgery there was not too much that could be done. Therefore, the department has found that the complaint of Facility failed to observe resident's change in condition was UNFOUNDED.

Allegation: Facility did not obtain timely medical treatment for resident.

LPA conducted interviews and reviewed statements from R1’s POA. Resident #1 (R1) was receiving hospice services, 5 times a week. It was noted in R1 case plan the plan to seek medical treatment and to contact with hospice first in matters relating to medical emergencies. LPA conducted interviews, per the Podiatrist whom saw R1 on 3/30/20, the recommendations were if R1 was in pain to keep legs down to increase circulation in the lower extremity, massage and increase walking. Per a written statement dated 5/20/20 from the Podiatrist, there was an additional request for an appointment, however podiatrist stated” that there is not much else that could be done from a podiatrist standpoint and that resident should be seen by a vascular specialist due to the current circulation issues”. R1 declined moving further with any other treatments and passed away on 7/30/20. The cause of death was Cardiorespiratory arrest. The allegation of Facility did not obtain timely medical treatment for resident is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Therefore the department has dismissed the complaint.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021

LIC9099 (FAS) - (06/04)

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