336403516-4-27-2023-18-AS-KCLS-CRBT88-20230428142955

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336403516
Report Date: 04/27/2023
Date Signed: 04/27/2023 10:55:30 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
10/19/2020 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201019121342

FACILITY NAME:	SUN CITY GARDENS		FACILITY NUMBER:	336403516
ADMINISTRATOR:	TED HOLT		FACILITY TYPE:	740
ADDRESS:	28500 BRADLEY ROAD		TELEPHONE:	(951) 679-2391
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	0	CENSUS: 60	DATE:	04/27/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Robin Rebollar & Bituin "Twinkie" Garcia		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

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Resident developed a stage 3 pressure injury while in care
Facility staff left resident in soiled clothing for an extended period of time
Facility staff did not seek medical attention in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced visit to the facility to deliver the findings on the above allegations. LPA met with MS Rebollar and MS Garcia. The Department conducted investigation into allegation of neglect of R1. The Investigation consisted of records review and interviews with relevant parties.

Investigation revealed that from time period of at least August 19, 2020, to October 16, 2020, staff neglected R1. On or about August 19, 2020, facility staff observed a wound on R1 coccyx area. On August 23, 2020, facility LVN reported wound to R1 physician as a Stage II and requested treatment.
Wound care was ordered on August 24, 2020, to apply Santyl to coccyx area daily & cover w/ island dressing X 14 days then re-assess. This care was to be completed by facility LVNs. However, wound care was not documented as being done daily. From August 30, 2020, to October 7, 2020, only 13 days were noted as wound care being done. R1 was not on hospice nor received home health services during this time period.
****Continuation in LIC9099C ****

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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 5

Control Number 18-AS-20201019121342

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: SUN CITY GARDENS	FACILITY NUMBER: 336403516
	VISIT DATE: 04/27/2023

NARRATIVE

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During investigation, S1 reported that he received a call at end of September (2020) from S2 asking him to assess R1 due to concern about the wound and wanted him to look at it. S1 reported that it was his understanding that R1 was on hospice or home health. S1 went to the facility approximately two weeks later (October 14, 2020) for a routine visit and to see R1. S1 assessed resident to have Stage III wound. It is not indicted that wound care or treatment was initiated at this time. It was determined thru investigation that medical attention was not sought for R1 until October 16, 2020, when R1 was admitted to the hospital. Staff interviews confirmed that during this time period (at least from August 19, 2020, to October 16, 2020) R1 coccyx wound was getting larger and not healing. There was staff statement made that there were no physician visits (on site or via “tele” visit) done due to inability to get an appointment.

Per medical records, upon admission to the hospital on October 16, 2020, R1 was uncommunicative. Evaluation of the sacral (coccyx) decubitus was completed and it was found to be at a stage III. R1 was admitted to the hospital for treatment and subsequently was discharged to higher level of care on October 19, 2020.

The Department investigated the allegation that facility staff neglected R1 incontinent needs.
According to facility interview, R1 had a history of taking medication for constipation and had bowel movements every 2-3 days. Staff also reported that the longest period between bowel movements was 4 days. Physician report and facility assessment tool reviewed indicate that R1 needed assistance with incontinent care and monitoring of skin. Facility records did not show documentation to support that assistance and monitoring of R1 incontinent care needs was being provided as needed. From at least October 5, 2020, to October 14, 2020, there were multiple times on facility documentation where there was no indication that incontinent care was provided to R1. On October 16, 2020, when R1 went to the hospital, medical records revealed that R1 had a large fecal impaction that caused R1 anal area to be dilated. Medical staff removed between 5 and 10 pounds of stool. It was also reported that R1 had fecal smear and urine in incontinence brief.

The Department investigated the allegation that facility staff did not seek medical attention for R1 in a timely manner. Based upon interviews and records review, it was found that for at least for 2 months (at or around August 19, 2020, until October 16, 2020), R1 had a pressure injury (wound) on coccyx area which required treatment and care. ****Continuation in LIC9099C ****

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 18-AS-20201019121342

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: SUN CITY GARDENS	FACILITY NUMBER: 336403516
	VISIT DATE: 04/27/2023

NARRATIVE

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As found thru investigation, R1 had other physical conditions (contractures, fecal impaction) that also needed medical care. Per hospital Physician, it was indicated that R1 had been in bed for a long time because it was apparent, R1 had a lack of muscle use. In addition, this same physician reported that R1 wound was not new and took months and not weeks for it to develop. According to physician, resident arrived at the hospital on October 16, 2020, with upper and lower extremities contracted, with soiled diapers (with feces) and a fecal impaction. In addition, medical records revealed that R1 also had a urinary tract infection, dehydration, and a slow resting heart rate. Physician further indicated that R1 required a higher level of care and should have been taken to the hospital sooner.

Based upon investigation, the preponderance of the evidence standard has been met, therefore the allegation that staff neglect resulted in sustaining a Stage III pressure injury (wound) to coccyx area is substantiated. Evidence supports that R1 had a wound and facility staff neglected to ensure care and services was provided and/or was received to meet R1 needs. An immediate civil penalty of $500 is assessed. The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(f).

An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to MS Rebollar and MS Garcia..

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 18-AS-20201019121342

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: SUN CITY GARDENS	FACILITY NUMBER: 336403516
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/28/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities: ...Residents in privately operated RCFEs shall have all of the following...rights: To care, supervision, & services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, & competency to meet their needs. This requirement was not met as evidenced by	1 2 3 4 5 6 7	Licensee stated to submit signed statement of understanding on CCR 87468.2(a)(4) and submit to LPA Javier Prieto by POC due date.
	8 9 10 11 12 13 14	Based on interviews and records review, it was found that from at least August 19, 2020, to October 16, 2020, Licensee failed to ensure that R1 received the care, supervision & services to meet their needs. R1 was observed to have a Stage II wound on coccyx area on or about August 19, 2020, but it was found that treatment and care for the wound was not provided as needed. On October 16, 2020, R1 was admitted to the hospital and same wound was assessed to be at a Stage III. This violation posed an immediate risk to R1.	8 9 10 11 12 13 14
Type A 04/28/2023 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities: ...Residents in privately operated RCFEs shall have all of the following...rights: To be free from neglect…This requirement was not met as evidenced by;	1 2 3 4 5 6 7	Licensee stated to submit signed statement of understanding on CCR 87468.2(a)(8) and submit to LPA Javier Prieto by POC due date
	8 9 10 11 12 13 14	Based upon interviews and records review, it was found that licensee failed to insure that R1 was free from neglect of their incontinent care. According to medical records, R1 was admitted to the hospital on October 16, 2020, with soiled incontinent product. R1 was also assessed and found with fecal impaction. Medical records note that hospital staff removed at least between 5 and 10 pounds of stool. There were no facility records observed that support that R1 incontinence condition was managed as required by licensee. This violation posed an immediate risk to R1.	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: Karen Clemons	TELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20201019121342

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: SUN CITY GARDENS	FACILITY NUMBER: 336403516
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/28/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465(a)(1) INCIDENTAL MEDICAL & DENTAL CARE - The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions & needs of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated to submit signed statement of understanding on CCR 87465(a)(1) and submit to LPA Javier Prieto by POC due date
	8 9 10 11 12 13 14	Based on interviews and file review, R1 had several physical conditions (wound, contractures, fecal impaction) that required care during this time period. However, it was not until October 16, 2020, when R1 was sent to the hospital. This violation posed an immediate risk to R1	8 9 10 11 12 13 14
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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: Karen Clemons	TELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

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