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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426054
Report Date: 09/30/2021
Date Signed: 09/30/2021 01:56:24 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
11/04/2019 and conducted by Evaluator Deborah Mullen
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191104153922
FACILITY NAME:CALEO BAY ALZHEIMER'S SPECIAL CARE CENTERFACILITY NUMBER:
336426054
ADMINISTRATOR:WILKIN, RONDAFACILITY TYPE:
740
ADDRESS:47805 CALEO BAY DRIVETELEPHONE:
(760) 771-6100
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:66CENSUS: 57DATE:
09/30/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Sheila Fike, Executive DirectorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident sustained multiple falls due to neglect
Resident sustained multiple injuries due to neglect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Deborah Mullen delivered the findings of the above allegations. LPA met with Sheila Fike, Executive Director. The Department investigation included interviews with staff, medical personnel and a review of Resident 1’s (R1’s) records.

Interviews with staff revealed R1 had sustained multiple unwitnessed falls. The facilities Health Services Director indicated R1’s doctor had ordered physical therapy and that R1 went through evaluating treatments, gait training, a sensor light in R1’s room was on twenty-four hours a day and R1 was reminded to use a walker. However, interviews revealed, not all staff were aware R1 was a fall risk. Staff interviews also revealed, not all staff were aware of their responsibilities in response to R1’s falls.

A review of facility Progress Notes confirmed R1 sustained falls on January 1, 2019, March 3, 2019, March 6, 2019, March 25, 2019, August 29, 2019, September 4, 2019, October 8, 2019 and October 26, 2019. Based on the Department’s investigation there is corroborating evidence to support the allegation that R1 sustained multiple falls due neglect, therefore this allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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-20191104153922
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: CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER
FACILITY NUMBER: 336426054
VISIT DATE: 09/30/2021
NARRATIVE
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On October 26, 2019 at approximately 0600 R1 was observed sitting in a chair by the nurses’ station with a blood face and injuries to the lip and eye. R1 was sent to the hospital and was diagnosed with a superficial laceration of the right upper lip with minimal swelling, bilateral lower extremity trace edema, multiple superficial skin tears in the lower extremities, multiple bruises, closed head contusion, closed fracture of multiple ribs of right side, initial encounter and hemopneumothorax on right side. Staff interviews did not provide evidence as to how R1 sustained the injuries. Staff indicated R1 was checked on during the overnight shift, however, no one observed R1 fall, nor did anyone observe how R1 obtained the injuries. Staff interviews indicated residents are to be checked on every two hours, however the investigation did not provide sufficient evidence to show R1 was checked on every two hours on the night of October 26, 2019. Based on the Departments investigation there is corroborating evidence to support the allegation that R1 sustained multiple injuries due to neglect, therefore this allegation is substantiated.

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 and a copy of this report, along with LIC9099D and appeal rights were provided to Sheila Fike.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20191104153922
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: CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER
FACILITY NUMBER: 336426054
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2021
Section Cited
CCR
87466
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Observation of the Resident:
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee 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.
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Executive Director will ensure staff are provided training on observation of residents and ensure their needs are being met. Proof of training will be submitted by 10/8/21.
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This requirement was not being met as evidenced by: Based on interviews and record reviews, between January 1, 2019 and October 26, 2019, R1 sustained multiple falls. Licensee did not ensure staff had been sufficiently informed of R1’s fall risk and/or what precautions were to be used to mitigate further falls. This posed a potential health and safety risk to resident in care.
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Type A
10/08/2021
Section Cited
CCR
87411(a)
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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 being met as evidenced by:
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Executive Director will ensure staff are trained on expectations relating to their knowledge of residents care plan to ensure their needs are met. Proof of training will be submitted by 10/8/21.
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 On October 26, 2019 R1 was observed with a bloody face and injuries to eye and lip. Staff interviews could not provide evidence as to how R1 sustained the injuries. This posed an immediate health and safety risk to resident in care.
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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 ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3