336426029-12-23-2021-18-AS-DMUN-CERUY4-20220525155915

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426029
Report Date: 12/23/2021
Date Signed: 12/23/2021 09:37:00 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
07/13/2020 and conducted by Evaluator David Cuevas

COMPLAINT CONTROL NUMBER: 18-AS-20200713134128

FACILITY NAME:	CALOAKS SENIOR LIVING		FACILITY NUMBER:	336426029
ADMINISTRATOR:	AMELIA ALADIN		FACILITY TYPE:	740
ADDRESS:	3891 POLK STREET		TELEPHONE:	(951) 689-6162
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92505
CAPACITY:	74	CENSUS: 63	DATE:	12/23/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	LVN, Melissa Bridges		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff neglect resulted in a resident's death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Cuevas delivered the findings of the above allegation. LPA met with staff Melissa Bridges. The Department investigation included interviews with staff, residents, law enforcement and medical personnel and a review of resident 1’s (R1’s) medical records.

The information received during staff interviews revealed that R1 sustained an unwitnessed fall outside on the patio on July 11, 2020. Staff stated R1 was found outside by another resident (R2) at approximately 3pm. R2 found R1 outside, lying unresponsive on the asphalt underneath the uncovered facility patio. R2 notified facility staff and staff contacted 911.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: David Cuevas	TELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

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-20200713134128

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: CALOAKS SENIOR LIVING	FACILITY NUMBER: 336426029
	VISIT DATE: 12/23/2021

NARRATIVE

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Based on the investigation completed, there was corroborating evidence to support the allegation that staff neglect resulted in R1’s death. On July 11, 2020, at approximately 3:15pm, R1 was transported by paramedics to the hospital. According to medical records R1’s body temperature was measured at 109.2 degrees F (upon admittance to the hospital. The investigation revealed, according to the National Weather Service, on July 11, 2020 the temperature in the local area was 97 degrees F at 11:53am, 101 degrees F at 12:53pm, 103 F degrees at 1:53pm and 104 degrees F at 2:53pm.

Medical records indicate that on July 11, 2020, R1 was diagnosed with heat stroke, dehydration and second and third degree burns to the bilateral upper extremities, bilateral legs, buttocks and lower back area, estimated at 30-40% of R1’s body surface area. An autopsy report cited the cause of death as “Hyperthermia due to environmental heat exposure.”

Staff interviews revealed residents are checked on every 1 to 2 hours. Interviews further revealed that R1’s whereabouts were unknown by staff from approximately 12pm to 3pm. A review of a law enforcement report divulged information from medical staff interviews, which revealed R1’s injuries were consistent with a person who had fallen onto an asphalt or concrete surface and laid there for hours. Therefore, this allegation is substantiated for neglect resulting in R1’s death.

A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49.

An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to the Staff, Melissa Bridges.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: David Cuevas	TELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200713134128

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: CALOAKS SENIOR LIVING	FACILITY NUMBER: 336426029
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 12/23/2021 Section Cited HSC 1569.269(a)(6)	1 2 3 4 5 6 7	1569.269(a)(6) Enumerated rights; severability - Residents of residential care facilities for the elderly shall have all of the following rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee, will install surveillance cameras in blind spots at the facility, conduct staff training on proper supervision, and designate a specific staff to conduct frequent head counts of all residents. Due date for plan of correction is 1/06/22.
	8 9 10 11 12 13 14	Facility staff were not competent in meeting R1 needs. Facility staff failed to properly supervise R1. Following an unwitnessed fall, R1 laid outside for hours and died of hyperthermia due to environmental heat exposure	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: David Cuevas	TELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

LIC9099 (FAS) - (06/04)

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