331880740-7-13-2023-18-AS-NBRN-CTXTHN-20230721144501

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880740
Report Date: 07/12/2023
Date Signed: 07/13/2023 07:52:36 AM

Unsubstantiated

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2021 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210301143619

FACILITY NAME:	GRACIOUS CARE HOME		FACILITY NUMBER:	331880740
ADMINISTRATOR:	ZHAO, NA		FACILITY TYPE:	740
ADDRESS:	12515 HUDSON RIVER DRIVE		TELEPHONE:	(951) 444-6651
CITY:	EASTVALE	STATE: CA	ZIP CODE:	91752
CAPACITY:	6	CENSUS: 3	DATE:	07/12/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Nidya Reynoso, Caregiver		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff did not ensure that resident was repositioned
Facility staff did not dispense medication as prescribed
Facility staff did not ensure that resident had an adequate amount of food
Facility staff did not ensure that resident had an adequate amount of water
Facility is increasing resident's fees without proper notice

INVESTIGATION FINDINGS:

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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above. During the course of this investigation LPA received and reviewed R1's hospice records dated 02/15/2021 through 02/25/2021. LPA reviewed R1's pre placement appraisal dated 2/16/2021, R1's physician report dated 02/12/2021, and R1's post acute order summary report dated 2/15/2021. Investigation included LPA tour of the facility on 03/10/2021, 06/21/2023, and 07/12/2023. Tour consisted of review of medications, assessment of food supply, and observing availability of food and drink for the residents. Facility tour dates revealed that the facility had sufficient supply of perishables and non perishables on hand. On 7/12/2023 LPA observed the lunch meal being served. Lunch was consistent with nutritional guidelines, hotdog on a bun, potatoes, fruit, and medium glass full of a juice and water were being served.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

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-20210301143619

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
, CA 92507

FACILITY NAME: GRACIOUS CARE HOME	FACILITY NUMBER: 331880740
	VISIT DATE: 07/12/2023

NARRATIVE

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Investigation revealed the following: LPA review of R1’s records revealed post acute order summary indicated that R1 has orders for topical treatment to be applied to sacrum for pressure injury for 21 days. R1 had a wound with treatment at time of moving in to this facility on 02/16/2021 and moved approximately 30 days later. R1 was assessed for hospice services on 2/15/2021, on page 5 of 7 indicate existing wound/skin impairment but is not specific to what the skin impairment or wound is. It is alleged care staff the were not rotating the resident which resulted in bed sores. Review of the records indicate that R1 arrived to the facility under hospice care and had orders for wound care. Hospice noted dated 3/1/2021 report stage II pressure injury on sacro-coccyx ; altered skin status-t/t pressure injury on left posterior leg. There is no information revealed that will verify that the pressure injuries were the result of staff not turning the resident as they were documented to exist prior to moving into the facility. It is alleged that staff did not dispense medications as ordered. During the course of this investigation the medications and records had been removed from the facility. Interview with the facility administrator reports It was really hard to do physical care because R1 would reject meds and spit them out. There is no available documentation to support this information. It is alleged facility staff did not ensure that resident had an adequate amount of food and adequate amount of water. LPA tours and review of food supply did not reveal a deficit in availability of food and water for the residents on those dates. It is alleged that facility is increasing resident's fees without proper notice. Interview with administrator indicated that during the preadmission R1 was presented one way and after 30 day reassessment was needed and it was determined that R1 required more care than initially indicated and there was notification of a rate increase due to 30 day assessment of care needs.

We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

LIC9099 (FAS) - (06/04)

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