336413282-11-9-2023-18-AS-RSTS-CYPNU9-20231220094555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336413282
Report Date: 11/09/2023
Date Signed: 11/09/2023 01:05:58 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
09/26/2022 and conducted by Evaluator Janira Arreola

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220926205159

FACILITY NAME:	TEMPLE COURT SENIOR CARE		FACILITY NUMBER:	336413282
ADMINISTRATOR:	ESTA HOBBS		FACILITY TYPE:	740
ADDRESS:	40009 TEMPLE CT.		TELEPHONE:	(951) 461-4750
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY:	6	CENSUS: 0	DATE:	11/09/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee, Esta Hobbs		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident sustained fracture while in care due to staff neglect
Staff mismanaged resident's medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate and deliver findings on the above allegations. LPA met with Licensee, Esta Hobbs, who was informed of the purpose of the visit. The department conducted interviews and records reviews.

It was alleged that Resident#1 (R1) sustained a fracture on 09/11/2022 after sustaining three (3) falls at the facility due to staff neglect.

Hospital discharge records dated 09/12/2022, showed R1 had a diagnosis of a comminuted displaced right femur fracture. Based on staff interviews, three (3) staff assisted R1 on 9/11/2022. Staff reported R1 was the only “wanderer” and that R1’s responsible party had informed the facility that R1 was a “fall risk”. A review of hospice notes dated 08/16/2022 revealed facility staff received training for fall prevention.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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 18-AS-20220926205159

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TEMPLE COURT SENIOR CARE	FACILITY NUMBER: 336413282
	VISIT DATE: 11/09/2023

NARRATIVE

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Staff interviews revealed R1 had three (3) unwitnessed falls on 9/11/22 at 9:30pm, 11:30pm, and into 9/12/22 at 1:30am. Staff described the first two (2) falls as “slips”. Staff interviews revealed after the first fall, R1 was found by Staff #1 (S1) in a seated position on the floor. S1 had called Staff #2 (S2) to assist R1 off the floor. After the second fall at 11:30pm, again R1 was found in a seated position and assisted by S1 and S2 off the floor. Staff stated R1 reported they were okay after the first two (2) falls and stated R1 was given an assessment to determine if there were any significant injuries or bruises. Interviews revealed that staff reported none were found. Written document to corroborate this statement was not provided.

R1 fell a third time 9/12/22 at 1:30am. Staff reported R1 had one of their legs bent, and in an “unnatural position”. S1 contacted Staff #3 (S3) for assistance. Staff interviews revealed R1 expressed being in significant pain, and staff called 911. Staff interviews revealed the measures taken to increase supervision of R1, were that R1 had a pendant they could press if staff were needed.

A facility document titled “Falls Addendum Service Plan and Intervention Protocol”, dated 07/02/2022 signed by R1’s responsible party and the licensee. Item #5 on the documents reads in part, “Placement of restless resident who is in danger of falling in constant view of caregiver by not leaving him/her unattended and out of eyesight.”

Staff interviews revealed the measures taken to increase supervision of R1, were that R1 had a pendant they could press if staff were needed. The interview did not reveal any further steps taken to increase supervision of R1. Therefore, based on the above, the allegation is substantiated.

An immediate civil penalty of $500 is being assessed. In accordance with Health and Safety Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 18-AS-20220926205159

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TEMPLE COURT SENIOR CARE	FACILITY NUMBER: 336413282
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/10/2023 Section Cited CCR 87468.2(a)	1 2 3 4 5 6 7	(a) In addition…residents…shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in...competency to meet their needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee agreed to conduct a re-training with staff on fall risk and supervision. Material used for training is to be sent to LPA by the POC due date
	8 9 10 11 12 13 14	Based on interviews and records review it was found R1 had (3) unwitnessed falls on the same date. Where staff failed to supervise the resident, resulting in R1 sustaining a femoral fracture. This poses an immediate health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type A 11/10/2023 Section Cited CCR 87465(5)(h)	1 2 3 4 5 6 7	(h)(5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.	1 2 3 4 5 6 7	The licensee will send LPA proof of material to be covered during staff in service to properly handel resident medications. This is due by the POC due date.
	8 9 10 11 12 13 14	This requirment was not met as evidenced by: Based on interview and record review the licensee mismanged the medication by prepouring it for R1 for a full day in advance. This posed an immediate personal	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: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 18-AS-20220926205159

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TEMPLE COURT SENIOR CARE	FACILITY NUMBER: 336413282
	VISIT DATE: 11/09/2023

NARRATIVE

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It was alleged that “Staff mismanaged resident's medication.” Allegedly, R1’s medication was being kept in weekly pill boxes where it was found that medication #1 (M1), Medication #2 (M2), and medication #3 (M3) were found twice in each box. This would have resulted in R1 taking a double dose of these medications.

The LPA conducted staff interviews which revealed that staff were prepouring medications for the day before during this time. LPA conducted a review of letter that was sent to the staff on medication error. Staff interviews revealed that they were aware of the note but denied a medication error occurred. Records review was conducted on the dosage for M1, M2, and M3. LPA reviewed centrally stored list for R1 and found that all three medications were to be given once at bedtime. Therefore, based on the above the allegation is found to be substantiated at this time.

Findings that are substantiated mean, the preponderance of the evidence standard has been met. Deficiencies is being cited for the substantiated allegation, and plans of correction was created with the licensee.

An exit interview was conducted where this report, deficiency page, civil penalty page, and appeal rights were reviewed and provided to Licensee, Esta Hobbs.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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
RIVERSIDE ASC, 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
09/26/2022 and conducted by Evaluator Janira Arreola

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220926205159

FACILITY NAME:	TEMPLE COURT SENIOR CARE		FACILITY NUMBER:	336413282
ADMINISTRATOR:	ESTA HOBBS		FACILITY TYPE:	740
ADDRESS:	40009 TEMPLE CT.		TELEPHONE:	(951) 461-4750
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY:	6	CENSUS: 0	DATE:	11/09/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee, Esta Hobba		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff did not provide resident with the proper equipment to assist with ambulation

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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 18-AS-20220926205159

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TEMPLE COURT SENIOR CARE	FACILITY NUMBER: 336413282
	VISIT DATE: 11/09/2023

NARRATIVE

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Staff interviews were conducted which revealed staff was assisted R1 in using their walker. Facility did not have documentation to corroborate this. Based on the above information it was found that the allegation is unsubstantiated at this time at this time.

Findings that are unsubstantiated mean that although the allegation is valid, the preponderance of the evidence standard has not been met.

An exit interview was conducted with licensee, Esta Hobbs where this report was reviewed and provided to them.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 6