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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336402994
Report Date: 09/29/2023
Date Signed: 09/29/2023 02:18:23 PM

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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220407125449
FACILITY NAME:LIFESTYLE HOME CAREFACILITY NUMBER:
336402994
ADMINISTRATOR:MARY MATEASFACILITY TYPE:
740
ADDRESS:5377 CAROL WAYTELEPHONE:
(951) 684-5833
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:6CENSUS: 3DATE:
09/29/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee/Administrator Mary Mateas and Steven MateasTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff neglect resulted in resident #1 (R1) sustaining an unstageable pressure injury.
Staff did not notify resident's authorized person of a change in health condition.
INVESTIGATION FINDINGS:
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On 09/29/2023 at 01:00 PM, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott met with Licensee/Administrator Mary Mateas and staff Steven Mateas at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPA Brown explained the purpose of the requested Office Visit.

The Department investigation included interviewing staff, residents, collecting pertinent records and records review. Based on the evidence collected during the investigation, the Department staff determined that there was corroborating evidence that Resident 1 (R1) sustained a stage 3 pressure sore while in care (Allegation #1). Department staff reviewed R1’s medical records. Medical records show that on 04/03/2022, R1 was transported to the hospital and unstageable pressure ulcer in R1’s sacral area was observed on hospital admission and R1 was later diagnosed with “Unstageable Sacral Area on Admission.
*** Continuation in LIC9099 ***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
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 6
Control Number 56-AS-20220407125449
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: LIFESTYLE HOME CARE
FACILITY NUMBER: 336402994
VISIT DATE: 09/29/2023
NARRATIVE
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R1 was admitted to the facility in 2019. R1 was considered non-ambulatory and used a wheelchair for mobility. R1 was paralyzed on right side of body and had limited mobility. Physician assessment in facility records indicates that R1 was incontinent and needed staff assistance with toileting needs, including changing of incontinent briefs. In addition, R1 needed care and assistance with activities of daily living such as bathing, dressing, and eating. R1 did not have a history of skin breakdown, according to assessment. Per investigation, R1 did require two people for transfer.

Per staff interviews, something described as a “small scratch” was observed on R1’s sacral area on March 31, 2022, several days prior to being admitted to the hospital. According to facility documentation, the area was described on April 1, 2022, as “red (irritation).” Facility staff did not seek medical assistance regarding these observations. Rather, facility staff treated the “scratch” with “diaper cream” and Neosporin. In addition, facility staff reported that R1 would spend most of the day in a recliner or wheelchair.

Investigation revealed that on April 3, 2022, R1 was admitted to the hospital due to vomiting. Upon admission, medical records show that R1 was diagnosed with an unstageable pressure injury to sacral area, with a Stage 1 pressure injury to mid upper back and abrasions to right hand and right knee. Facility records nor staff interviews revealed observations of pressure injuries as diagnosed.

Based on the Department investigation, it is concluded that there is sufficient evidence to substantiate allegation of staff neglect of R1. It was evident that R1 required staff assistance with activities of daily living, including incontinent care. However, it was found that facility staff failed to provide the services needed by R1 to meet R1 needs.

*** Continuation in LIC9099C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 56-AS-20220407125449
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: LIFESTYLE HOME CARE
FACILITY NUMBER: 336402994
VISIT DATE: 09/29/2023
NARRATIVE
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As a result, R1 sustained an unstageable pressure injury to sacral area while in care. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An immediate Civil Penalty in the amount of $500.00 was assessed. The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(f).

Regarding allegation #2, Staff did not notify resident's authorized person of a change in health condition, LPA Brown determined that there was corroborating evidence that staff did not notify R1’s authorized person, the Inland Regional Center (IRC), of a change in health condition. Interview with Staff 1 (S1) indicated that Staff 2 and Staff 3 did not report a change in health condition specifically R1’s pressure injury to S1. In addition, an interview with IRC Consumer Services Coordinator revealed that staff did not notify them of R1’s change in health condition, and specifically indicated that no pressure injury was reported to them, and they only found out of the reported change of health condition from the hospital.

Based on the information and interviews gathered the allegation Staff neglect resulted in resident #1 (R1) sustaining an unstageable pressure injury (Allegation #1) and Staff did not notify resident's authorized person of a change in health condition (Allegation #2), are 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. Please see LIC9099D for deficiencies cited.



An exit interview was conducted where this report (LIC9099), LIC9099D, LIC421IM and Appeal Rights were discussed, and a copy was provided to Licensee/Administrator Mary Mateas and staff Steven Mateas at the conclusion of the visit.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 56-AS-20220407125449
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: LIFESTYLE HOME CARE
FACILITY NUMBER: 336402994
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (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…(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency… This requirement was not met as evidenced by:

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The licensee stated to train all staff on CCR 87468.2 (a) (4) and submit Training Log to LPA Brown by POC due date.
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Based on interviews & records review, it was found that Licensee did not ensure R1 received the care, supervision & services to meet their needs. On April 3, 2022, R1 was admitted to the hospital and was diagnosed with an unstageable pressure injury to their sacral. However, it was found that treatment and care for the injury was not being provided as needed. This violation of regulation posed an immediate risk to R1.
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Type A
09/30/2023
Section Cited
CCR
87466
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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... This requirement is not met as evidenced by:
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The licensee stated to train all staff on CCR 87466 and submit Training Log to LPA Brown by POC due date.
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Based on observations, interviews and record review, the Licensee did not comply with section cited above by not reporting to R1's physician and R1's responsible person the observed changes or deterioration of R1's physical health condition and by not ensuring that such changes are documented which poses an immediate health, safety, and personal rights risks to resident in care.
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
04/07/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220407125449

FACILITY NAME:LIFESTYLE HOME CAREFACILITY NUMBER:
336402994
ADMINISTRATOR:MARY MATEASFACILITY TYPE:
740
ADDRESS:5377 CAROL WAYTELEPHONE:
(951) 684-5833
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:6CENSUS: DATE:
09/29/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee/Administrator Mary Mateas and Steven MateasTIME COMPLETED:
02:20 PM
ALLEGATION(S):
1
2
3
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9
Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
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On 09/29/2023 at 01:00 PM, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott met with Licensee/Administrator Mary Mateas and staff Steven Mateas at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPAs Brown and Wolcott explained the purpose of the requested Office Visit.

The investigation was conducted by Department staff. The investigation consisted of file review and interviews with relevant parties. The allegation indicated that Staff did not seek medical attention for resident in a timely manner. Evidence shows that staff did seek medical attention for Resident 1 (R1) in a timely manner. On April 3, 2022, around 8:30am facility staff first observed R1 vomit a dark colored substance that did not resemble blood. Staff notified Administrator Mary Mateas of the situation. Around 4:00 PM, R1 vomited the same dark substance a second time causing facility staff to call emergency services (911). ***Continuation on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 56-AS-20220407125449
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: LIFESTYLE HOME CARE
FACILITY NUMBER: 336402994
VISIT DATE: 09/29/2023
NARRATIVE
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Evidence shows that the facility staff called American Medical Response (911) on April 3 for R1’s complaint of Nausea and Vomiting. Staff interviews revealed that R1 was not exhibiting any unusual behavior or complaining of pain. Moreover, it was reported that facility staff monitored R1’s blood pressure and oxygen levels until emergency services arrived.

There is insufficient evidence to prove that Staff did not seek medical attention for resident in a timely manner. The evidence also demonstrates that the facility acted appropriately by calling AMR when R1 complaint of nausea/vomiting and monitored R1’s blood pressure and oxygen levels. Therefore, based on the evidence obtained during the Department's investigation, the allegation of Staff did not seek medical attention for resident in a timely manner is unsubstantiated at this time.

Although the allegation Staff did not seek medical attention for resident in a timely manner may have happened or are 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 where this report (LIC9099) was discussed and provided to Licensee/Administrator Mary Mateas and staff Steven Mateas.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6