336410303-7-8-2020-18-AS-EMAN-BRKN9X-20200716101637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336410303
Report Date: 07/08/2020
Date Signed: 07/08/2020 02:38:20 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
10/07/2019 and conducted by Evaluator Robbie Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20191007100108

FACILITY NAME:	SIMCARE HOMES LLC		FACILITY NUMBER:	336410303
ADMINISTRATOR:	PERLITA SIMAN		FACILITY TYPE:	740
ADDRESS:	155 BRACEBRIDGE ROAD		TELEPHONE:	(951) 780-3200
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92506
CAPACITY:	6	CENSUS: 4	DATE:	07/08/2020
		UNANNOUNCED	TIME BEGAN:	02:01 PM
MET WITH:	Wilfredo Siman, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Due to neglect resident developed a stage IV pressure injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Robbie Johnson contacted the facility to review the above allegation via telephone due to COVID-19. LPA identified herself and discussed the purpose of the call and the elements of the allegation with Administrator Wilfredo Siman.

The Department conducted investigation of allegation to include interviews and records review. When R1 was admitted to the facility in March 2015, R1 had several medical conditions which required care and supervision. In addition, R1 was bedridden and needed assistance with activities of daily living. In March 2019, R1 had right toe amputated due to what was described as “diabetic foot disease.” Review of home health records revealed that care was being provided by home health staff to this toe in addition to other pressure injuries on R1 lower extremities. Physician saw R1 and it was noted that R1 had Peripheral Vascular Disease which affected R1’s circulatory system. Investigation revealed that since March 2019, R1’s vascular disease was worsening and additional pressure injuries to lower extremities began to develop.
*Continued on next page*

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Robbie Johnson	TELEPHONE: (951) 248-0304
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2020

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-20191007100108

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: SIMCARE HOMES LLC	FACILITY NUMBER: 336410303
	VISIT DATE: 07/08/2020

NARRATIVE

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During this time, home health care was being provided to the new and ongoing pressure injuries. R1 remained in the facility while receiving care. Per investigation, it was found that the pressure injuries were determined to be related to the vascular disease. On August 7, 2019, R1 was taken to the hospital after it was indicated that R1 was “not feeling well.” Hospital records reviewed indicated that upon hospital admission, R1 was noted to a have Stage 1 sacral pressure injury on left buttock and Stage II sacral pressure injury on right buttock. In addition, multiple pressure injuries were observed on R1 lower extremities. As indicated upon review of home health records, the pressure injuries were being treated. In addition, it was determined that facility staff followed recommendations of nutrition and plan of care for R1. The allegation of neglect is determined to be UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

A copy of this report has been reviewed with and provided to the Administrator via email.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Robbie Johnson	TELEPHONE: (951) 248-0304
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2020

LIC9099 (FAS) - (06/04)

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