340310728-3-19-2021-27-AS-KHOS-C2JR6C-20210429124432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340310728
Report Date: 03/19/2021
Date Signed: 03/19/2021 03:09:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/08/2020 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 27-AS-20200608121921

FACILITY NAME:	VINSON'S CARE HOME		FACILITY NUMBER:	340310728
ADMINISTRATOR:	VINSON, CALDONIA		FACILITY TYPE:	740
ADDRESS:	6121 GILMAN WAY		TELEPHONE:	(916) 348-4067
CITY:	NORTH HIGHLANDS	STATE: CA	ZIP CODE:	95660
CAPACITY:	6	CENSUS: 4	DATE:	03/19/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Caldonia Vinson, Licensee		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained pressure sores while in care.

INVESTIGATION FINDINGS:

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On 3/19/2021, CCLD Investigative Branch (IB) concluded a complaint investigation received on 6/18/2020 which alleged that facility staff neglect resulted in resident R1 sustaining a large stage 3 decubitus ulcer. Licensing Program Analysts (LPAs) Michael Hood and Melissa Parks met with Licensee, Caldonia Vinson, to deliver complaint findings for the above allegation.

During the investigation, IB investigator conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

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 27-AS-20200608121921

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VINSON'S CARE HOME	FACILITY NUMBER: 340310728
	VISIT DATE: 03/19/2021

NARRATIVE

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During interview conducted with Licensee, Licensee stated she was notified by staff member S1 that R1 had a red area on their coccyx on 5/26/2020. Licensee looked at the area on 5/27/2020, and again on 5/28/2020, and detected a red area with a darker red spot in the center. Licensee stated the red area was not open, but there was a “slit” down the center, like a crack. Licensee stated R1 would “scoot” on their bottom and believed the wound was caused from R1’s scooting on the ground.

Interviews with facility staff indicated discrepancies regarding whether the wound was open or not. On 6/01/2020, R1 was seen by their regular physician, who sent R1 to the Emergency Room. Medical records show R1 was admitted to Sutter General Hospital on 6/01/2020 with a large open wound to the sacral area and an abscess on their left buttock. R1 underwent a surgical debridement and cultures were taken, in which R1 was positive for three bacterial infections, including Methicillin-resistant stafpylococcus aureus (MRSA). Interview with Sutter General Wound Care Director indicated that R1’s ulcer was a “pretty bad wound” and it would have taken longer than a week to become that severe. Wound Care Director stated that R1’s ulcer was a “pressure related” wound caused from not relieving the pressure.

R1 was admitted to Sutter General Hospital on 6/1/2020 and did not return to the facility. R1 was admitted to hospice care on 6/17/2020 and expired on 6/25/2020. Death certificate listed R1’s cause of death as “Sepsis,” with a secondary cause of death listed as “Sacral Decubitus Ulcer.” Sacramento County Sheriff’s Office investigation is still open and pending.

Based on interviews conducted by IB investigator and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. As a result of the resident’s death, the violation warrants an immediate civil penalty assessment per California Code of Regulations, Title 22 Division 6, Chapter 8, regulation 87466 in the amount of $500 for the date of 3/19/2021. An enhanced civil penalty assessment is under review and this civil penalty determination is pending. Your LPA will return on a future date to assess an enhanced civil penalty if warranted.
Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200608121921

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VINSON'S CARE HOME	FACILITY NUMBER: 340310728
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/22/2021 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 in physical (...) functioning and that appropriate assistance is provided when such observation reveals unmet needs. (...) This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will conduct in-service training for staff regarding observation of residents and response time. Licensee will submit to LPA information regarding in-service training, including time and date of in-service and training material, by POC due date of 3/22/21.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure resident R1 was treated for a wound in a timely manner after observation, which posed an immediate health, safety, and personal rights risk to the residents in care.	8 9 10 11 12 13 14
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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: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

LIC9099 (FAS) - (06/04)

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