331880802-5-30-2023-18-AS-JESL-CSD7FS-20230531213801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880802
Report Date: 09/16/2021
Date Signed: 05/30/2023 10:51:43 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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2021 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210909111310

FACILITY NAME:	MURRIETA GARDENS		FACILITY NUMBER:	331880802
ADMINISTRATOR:	NIARE FEASTER		FACILITY TYPE:	740
ADDRESS:	24200 MONROE AVE		TELEPHONE:	(951) 600-7676
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	72	CENSUS: 44	DATE:	09/16/2021
		UNANNOUNCED	TIME BEGAN:	10:49 AM
MET WITH:	Executive Director Niare Feaster		TIME COMPLETED:	03:47 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care.

INVESTIGATION FINDINGS:

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The following report is an amendment to the findings that were originally given on 9/16/2021.

Licensing Program Analyst (LPA) Javina George arrived unannounced at the facility to investigate and deliver findings for the allegation listed above. LPA met with Executive Director Niare Feaster and explained the purpose of the visit and elements of the allegation.

Department investigated allegation of staff neglect resulted in R1 developing pressure injuries. The investigation consisted of staff and resident interviews, and record review. On August 16, 2017, R1 was admitted to the facility. Upon admission, Resident #1 (R1) did not have any documented pressure injuries. On 12/12/19 R1 was admitted to hospice, for Parkinson's Diease, and at that time was noted to not have any pressure injuries. LPA reviewed the outside agency documentation form dated July 28, 2021, and notes that R1 has redness to their buttocks. Additional outside agency documentation form reviewed dated August 3, 2021, states R1 was noted to have stage 2 pressure injury located on R1s left inner buttock/coccyx.

Unsubstantiated

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: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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-20210909111310

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: MURRIETA GARDENS	FACILITY NUMBER: 331880802
	VISIT DATE: 09/16/2021

NARRATIVE

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LPA interviewed Executive Director Niare whom stated that if any resident was diagnosed with a stage 2 pressure injury, the facility's protocol would be to have the resident temporarily relocated to a rehab for healing or if the resident was receiving hospice services, to have the services increased to include wound care, which is what the facility has done in the past.

R1s resident appraisal dated April 28, 2018, notes that R1 requires a two person assist with transfers. R1s preplacement appraisal, health history section notes that R1 did not have a history of bed sores. Once the diagnosis of the stage 2 pressure injury was noted Documentation reviewed for R1 noting the Doctor ordered for R1 to only be in bed and up in their wheelchair during meal times as tolerated.

R1 was noted to be in their wheelchair despite the doctor's order outside of meal times. Per staff R1 would not stay in bed. However, no alternative plan was discussed or implemented to address repositioning or getting R1 up to relieve pressure.

Additionally, LPA reviewed documentation that revealed, a facility staff had requested for a third party to note the stage 2 pressure ulcer, to be defined as a small open area, as R1 would no longer be able to reside at the facility.

Based on interview and record review the allegation of Resident sustained pressure injuries while in care is UNSUBSTANTIATED. A finding that the complaint 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, and appeal rights was provided to Executive Director Niare Feaster.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 5 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, 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
09/09/2021 and conducted by Evaluator Javina George

COMPLAINT CONTROL NUMBER: 18-AS-20210909111310

FACILITY NAME:	MURRIETA GARDENS		FACILITY NUMBER:	331880802
ADMINISTRATOR:	NIARE FEASTER		FACILITY TYPE:	740
ADDRESS:	24200 MONROE AVE		TELEPHONE:	(951) 600-7676
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	72	CENSUS: 44	DATE:	09/16/2021
		UNANNOUNCED	TIME BEGAN:	10:49 AM
MET WITH:	Executive Director Niare Feaster		TIME COMPLETED:	03:47 PM

ALLEGATION(S):

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Facility failed to issue refund after resident moved out.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George arrived unannounced at the facility to investigate and deliver findings for the allegation listed above. LPA met with Executive Director Niasre Feaster and explained the purpose of the visit and elements of the allegation.
The department investigated the allegation of facility failed to issue a refund after resident had been discharged. R1 moved out of the facility on August 14, 2021. R1 had hospice services in place, and wound care was being provided.

LPA interviewed Wellness Director Brittany Kavanaugh who confirmed that a conversation between She and the hopsice agency did occur. Brittany had requested for the Nurse Practitioner to come to the facility and stage the pressure injury rather than someone that was not licensed, but denied stating that a resident could not remain at the facility if they had a stage (1) one or (2) two pressure injury.

Unsubstantiated

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: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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-20210909111310

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: MURRIETA GARDENS	FACILITY NUMBER: 331880802
	VISIT DATE: 09/16/2021

NARRATIVE

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LPA also interviewed Executive Director Niare whom denied having knowledge of the conversation occurring. Niare also stated that she does like to be forthcoming with information to responsible parties of what the future could look like should the pressure injury progress to a 3 or 4 even, un-stageable and that was the extent of the conversation.

Niare also stated that a verbal notice was given on August 13, 2021, by R1 responsible party and was accepted. LPA reviewed additional documentation that notes a discussion being had about R1 requiring more one on one care, on two separate occasions.

The allegation of facility failed to issue refund after resident moved out is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted and a copy of this report was provided to Executive Director Niare Feaster.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20210909111310

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: MURRIETA GARDENS	FACILITY NUMBER: 331880802
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 09/30/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	AMENDMENT: DEFICEINCY DISMISSED 87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs....	1 2 3 4 5 6 7	The licensee agrees to conduct an in-service on restricted and prohibited health conditions. Proof is to be submitted to the department by 5pm on the due date indicated.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by R1 developing a stage 2 pressure injury, with the signs being noted prior to the diagnosis, with no plan to prevent further injury. Based on observation, interview and record review the licensee did not observe a change in R1s condition 1 out of 1 times. This poses a potential health, safety and personal rights risks to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5