336425567-11-6-2023-18-AS-JDHS-CXMQ6P-20231116105348

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425567
Report Date: 11/06/2023
Date Signed: 11/06/2023 09:55:33 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,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/29/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201229100435

FACILITY NAME:	RISING STAR CARE HOME		FACILITY NUMBER:	336425567
ADMINISTRATOR:	JAMES REED		FACILITY TYPE:	740
ADDRESS:	30045 AUDELO STREET		TELEPHONE:	(951) 609-3300
CITY:	LAKE ELSINORE	STATE: CA	ZIP CODE:	92530
CAPACITY:	0	CENSUS: 0	DATE:	11/06/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	James Reed, Licensee/Administrator		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not observe changes in resident and inform a doctor.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Javina George made an unannounced visit to deliver findings for the allegation noted above. LPA George met with the Administrator/Licensee James Reed. LPA discussed the and explained the purpose of the visit and the elements of the allegation The investigation consisted of observations, interviews, and records review. Below are the findings of this investigation:

Regarding the allegation "Staff did not observe changes in resident and inform a doctor" it was alleged that Resident 1 (R1) had a change in condition and staff did not get medical aid. Medical records dated 12/28/2020 revealed that R1 had not eaten for at least two (2) days, prior to being admitted to the hospital on this same day. Interview with staff revealed R1 was observed with a change of condition on or about 12/15/2020. This change included R1 becoming non-verbal and acting confused. Interview with the administrator revealed they were aware R1 was confused and repeating themselves on or about 12/25/2020.

***Continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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 3

Control Number 18-AS-20201229100435

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: RISING STAR CARE HOME	FACILITY NUMBER: 336425567
	VISIT DATE: 11/06/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff interviews revealed that on 12/28/2020, R1 was observed to have “really bad swelling” to the hands and face, thus prompting staff to call 911. Medical record narrative from AMR dated 12/28/2020 revealed “staff on scene states” R1 “has been experiencing facial and upper extremity swelling for the past 2 days prompting them to call 911.” Upon admission to the hospital, based on the medical consult dated 12/28/2020, it was determined that R1 suffered from "an acute stroke in the right cerebellum and in the posterior parietal lobes bilaterally".

Facility staff did not contact 911, seek other medical attention nor report this change of condition to R1’s physician for several days. Based on interviews and records review the allegation of staff did not observe changes in resident and inform a doctor is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegations is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted, and a copy of this report, 9099C, 9099D, and appeal rights were provided to James Reed, Licensee/AdministratorElaine Fontilla, Caregiver.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 18-AS-20201229100435

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: RISING STAR CARE HOME	FACILITY NUMBER: 336425567
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 11/20/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of Resident The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any	1 2 3 4 5 6 7	The Licensee agrees to conduct an inservice on addressing wounds and pressure injuries. Proof of POC is to be submitted by 5pm on the due date indicated.
	8 9 10 11 12 13 14	This requirement was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation 1 time. Staff did not observe R1 to have a change of condition. This poses a potential health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3