336426550-7-2-2021-18-AS-RLAY-C4WL4S-20210714082559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426550
Report Date: 07/02/2021
Date Signed: 07/02/2021 10:33:06 AM

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
04/07/2020 and conducted by Evaluator Pauline Beschorner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200407164253

FACILITY NAME:	DESERT COVE ASSISTED LIVING AT DESERT HOT SPRINGS		FACILITY NUMBER:	336426550
ADMINISTRATOR:	HEYWOOD, ERIKA		FACILITY TYPE:	740
ADDRESS:	13660 MOUNTAIN VIEW ROAD		TELEPHONE:	(760) 671-7820
CITY:	DESERT HOT SPRINGS	STATE: CA	ZIP CODE:	92240
CAPACITY:	56	CENSUS:	DATE:	07/02/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Heather Scott		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident developed unstageable wounds while in care.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Pauline Beschorner made an unannounced visit to the facility to deliver findings regarding the above allegation. Upon arrival, LPA met with Administrator Heather Scott. LPA explained the purpose of the visit and was granted entry into the facility.

The allegation alleges resident developed unstageable wounds while in care. Based off record review obtained, records revealed R1 was admitted to the facility on January 25, 2018. Documentation revealed a skin tear, on the right hip, was observed and documented by facility staff on March 3, 2020. On March 6, 2020, R1 was seen by a physician. The physician noted “staff denies any pressure ulcers or open wounds" during this visit. Interview with the Administrator revealed staff performed basic first aid on a skin tear between March 6 and March 18, 2020. On March 18, 2020 a referral was made to Home Health for wound care as the skin tear on the right hip deteriorated. On March 20, 2020, Home Health developed a plan of care for R1 that included wound care to the right and left hip. As part of the plan of care R1 remained in the facility while receiving wound treatment three to four times per week. On March 25, 2020, a Home Health physician made a referral for consult and treatment by

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

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 2

Control Number 18-AS-20200407164253

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: DESERT COVE ASSISTED LIVING AT DESERT HOT SPRINGS	FACILITY NUMBER: 336426550
	VISIT DATE: 07/02/2021

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

Wound Masters. Wound Masters began seeing R1 on March 26, 2021 for the wounds to both the right and left hip. Wound Masters documentation revealed the onset of both “pressure ulcers,” to the right and left hip, was on March 20, 2020. On April 3, 2020, medical documents show home health physician diagnosed the right hip as a stage 4 “pressure ulcer” and the left hip as a stage 3 “pressure ulcer.” On April 5, 2020 R1 was sent out to the hospital for unrelated reasons and did not return to the facility.

Based upon the investigation, the progression of the pressure injuries are unclear. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted, and a copy of this report was provided to Administrator Heather Scott, whose signature on this form confirm the receipt of the above-mentioned documents.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2