336402166-4-14-2022-18-AS-EMAN-CEJPEZ-20220518111555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336402166
Report Date: 04/14/2022
Date Signed: 04/14/2022 09:49:23 AM

Substantiated

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
09/28/2020 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200928142900

FACILITY NAME:	JMP CARE HOME		FACILITY NUMBER:	336402166
ADMINISTRATOR:	EMELITA M. PRICE		FACILITY TYPE:	740
ADDRESS:	2771 CAMBRIDGE AVENUE		TELEPHONE:	(951) 766-5370
CITY:	HEMET	STATE: CA	ZIP CODE:	92545
CAPACITY:	6	CENSUS: 2	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Emelita Price		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Facility staff neglected Resident #1 (R1)
Facility staff failed to seek timely medical attention for Resident #1 (R1)

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegations. LPA Williams identified herself to Administrator, Emelita Price, who was also informed of the purpose of the visit. The investigation consisted of records review and interviews with staff, residents, and witnesses.

In regard to allegation #1, The Department determined, based upon investigation, that the facility staff failed to provide care and supervision to protect R1’s health and safety when during the course of R1 four year residence at facility, R1 sustained multiple injuries requiring medical attention as a result of what were identified as falls. During a fall on February 21, 2019, R1 sustained a left hip fracture which required surgery. On April 22, 2019, R1 sustained a right eye contusion as a result of a fall. Based upon review of

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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-20200928142900

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: JMP CARE HOME	FACILITY NUMBER: 336402166
	VISIT DATE: 04/14/2022

NARRATIVE

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resident records, there was no indication following these falls, that facility implemented a plan of care to minimize R1’s risk for future falls. According to R1 facility records dated June 2020, R1 was “subject to fall” and required a walker for ambulation due to diagnosis of Paraparesis of both limbs. It was noted that facility staff will monitor. In addition, Staff #2 (S2) reported during the investigation that R1 had been showing decline in functioning and started walking slower; however, S2 reported that R1 refused to use walker. In addition, S2 told Department staff that S2 did not consult a doctor about R1 refusal for assistive devices. Despite staff observing change in R1’s condition, there was no indication again that facility implemented a plan of care to minimize R1’s risk for future falls. Furthermore, in September 17, 2020, due to what was identified as another fall, R1 was transported to the hospital and subsequently diagnosed with fracture of the cervical vertebrae. The allegation that, facility staff neglected R1, is substantiated.

In regard to allegation #2, On 9/17/2020 at around 4:00 am, Staff #1 (S1) reported that they heard R1 get up to go to the bathroom. Then, R1 went back to R1 room but left the door open. S1 stated that this was very unusual for R1, so S1 decided to check on R1. When S1 entered the room, R1 was sitting on the floor with back leaning against the wall. S1 picked R1 up and put R1 back in bed. S1 reported no visible bruising or swelling to R1. However, S1 did not indicate if R1 was awake at the time of this incident nor was it indicated that S1 inquired with R1 as to R1’s condition immediately following the incident. S1 admitted to not reporting R1’s fall immediately to the facility administrator nor seeking medical attention or 9-1-1. S1 stated that at 11:00 am, R1 asked for assistance getting out of a chair and getting into bed. S1 stated that this was unusual for R1. S1 stated that R1 also complained of neck pain, which is when S1 decided to contact S2. It was reported that S2 arrived around 11:15 am. S1 had not called 9-1-1 prior to S2’s arrival even though S1 exhibited “unusual” behavior. S2 stated she found a “bump” on R1’s head and then called R1’s responsible party and 9-1-1. However, according to R1’s medical records, R1 was admitted into the hospital due to the fall, around 1:02 PM, approximately 9 hours after R1 initially fell. The allegation that, facility staff failed to seek timely medical attention for R1, is substantiated.

Based upon the evidence discovered in the investigation, including interviews and records review, allegation that facility staff failed to seek timely medical attention for R1 is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. This posed an immediate Health and Safety risk to residents in care.

See deficiencies cited on LIC 9099D. In addition, an immediate civil penalty will be assessed for violation

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200928142900

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: JMP CARE HOME	FACILITY NUMBER: 336402166
	VISIT DATE: 04/14/2022

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	resulting in injury. An exit interview was conducted where this report was discussed and a copy was provided to Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20200928142900

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: JMP CARE HOME	FACILITY NUMBER: 336402166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/15/2022 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of ... (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, .... This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	The licensee agreed to conduct training for all staff members on CCR 87468.2 and send proof to the department by POC date. Additionally, an immediate civil penalty is being assessed for not ensuring a care plan was in place for R1's fall prevention, which resulted in R1 sustaining a serious injury.
	8 9 10 11 12 13 14	Based on records review and interview, the licensee did not ensure that R1's personal right to be free of neglect. This is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 04/15/2022 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	The licensee agreed to conduct training for all staff members on CCR 87465 and implement a protocol for staff members to identify imminent health threats to the residents. Proof to the department should be obtained by POC date.
	8 9 10 11 12 13 14	Based on records review and interview, the licensee did not ensure that R1 received timely medical attention. This is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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