336405884-9-20-2021-18-AS-RLAY-C76V7X-20210924161150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336405884
Report Date: 09/20/2021
Date Signed: 09/20/2021 04:10:39 PM

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
12/01/2020 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201201123431

FACILITY NAME:	INTEGRATED CARE COMMUNITIES - A1		FACILITY NUMBER:	336405884
ADMINISTRATOR:	EMELY C. RODRIGUEZ		FACILITY TYPE:	740
ADDRESS:	14265 NASON STREET		TELEPHONE:	(951) 601-9100
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY:	22	CENSUS: 14	DATE:	09/20/2021
		UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Care Consultant, Luz Rodriguez		TIME COMPLETED:	04:26 PM

ALLEGATION(S):

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Facility staff failed to provide care and supervision to Resident 1 (R1) resulting in multiple pressure injuries.

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INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegation. LPA met with Care Consultant, Luz Rodriquez..
The Department investigated the allegation that the resident sustained a stage 3 pressure injury while in care. Information was gathered from interviews and a review of medical records obtained. It was revealed that Staff 1 (S1) became aware of an “abrasion” on R1’s left hip and coccyx on November 3, 2020. This was documented in facility records. By November 4, 2020, the area on the on the coccyx was noted by S1 to have changed in appearance. S1 did not inform R1’s hospice agency, primary care physician or responsible party until November 10, 2020. According to hospice nurse notes and facility nursing notes, the facility nurse assumed the responsibility of following physician’s orders in treating the pressure injuries to the hip and coccyx. The orders were given on November 10, 2020, which included treating the left hip pressure injuries daily with transparent dressing x14 days and the coccyx daily with dry dressing x14 days.
According to interviews with the hospice nurse it was determined that the pressure injury on the coccyx was a stage 2 on November 12, 2020.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

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-20201201123431

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: INTEGRATED CARE COMMUNITIES - A1	FACILITY NUMBER: 336405884
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/21/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	PERSONNEL REQUIREMENTS - GENERAL: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee shall ensure that residents are regularly observed for changes in condition and that notifications are made to the resident's physician and the resident's responsible person, including hospice if applicable. Staff shall always ensure that
	8 9 10 11 12 13 14	Facility stafff failed to show competency when staff failed to notify hospice of R1’s worsening condition and when staff deviated from physician’s order for treatment of pressure injuries. This posed an immediate Health and Safety risk to residents in care.	8 9 10 11 12 13 14	residents are receiving care to meet their needs. If a resident’s needs cannot be met, then a higher level of care may be needed. Proof of understanding and staff training log on Regulation 87411 shall be submitted to CCL by the POC due date of 9/21/2021..
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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: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
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)

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Control Number 18-AS-20201201123431

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: INTEGRATED CARE COMMUNITIES - A1	FACILITY NUMBER: 336405884
	VISIT DATE: 09/20/2021

NARRATIVE

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On November 17, 2020, during an in person visit with the hospice nurse, it was reported that the pressure injury on the coccyx had transitioned to a stage 3 and the pressure injury on the left hip became unstageable with necrotic tissue present. R1 had also developed a Deep Tissue Injury (DTI) on the left ankle.
Based upon interviews, facility staff failed to notify the hospice nurses when R1’s condition worsened and deviated from the physician’s order for the treatment of the pressure injuries by not using the proper dressing, not repositioning R1, and not keeping the pressure injuries covered with a dressing as ordered by the doctor.

Based on Department interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D.

The licensee was also advised that civil penalties may be assessed in accordance with Health and Safety Code §1569.49.

An exit interview was conducted where this report and appeal rights were discussed and provided to Ms. Rodriguez..

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

LIC9099 (FAS) - (06/04)

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