340310728-8-27-2021-25-AS-MHOD-C6AMNE-20210827094527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 340310728
Report Date: 08/27/2021
Date Signed: 08/27/2021 09:45:43 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

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:	08/27/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Caldonia Vinson, Licensee		TIME COMPLETED:	10:30 AM

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	On 8/27/2021, Licensing Program Analysts (LPAs) Michael Hood and Sabrina Calzada met with Licensee of facility Vinson’s Care Home, Caldonia Vinson, for a case management visit to follow up on a substantiated allegation of neglect. Prior to initiating visit, LPAs completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility and completed a facility risk assessment. LPAs ensured to apply hand sanitizer before visiting the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. On March 19, 2021, the Department concluded a complaint investigation which alleged that facility staff neglect resulted in resident (R1) sustaining a large stage 3 pressure injury. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87466 Observation of 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. During the investigation, an interview conducted with the licensee revealed, that the licensee stated she was notified by a staff member (S1) that R1 had a red area on R1’s coccyx on May 26, 2020. The licensee looked at the area on May 27, 2020, and again on May 28, 2020, and detected a red area with a darker red spot in the center. The licensee stated the red area was not open, however there was a “slit” down the center, like a crack. The licensee stated R1 would “scoot” on R1’s bottom and believed the wound was caused from R1’s scooting on the ground. Report continued on 809-C

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: VINSON'S CARE HOME	FACILITY NUMBER: 340310728
	VISIT DATE: 08/27/2021

NARRATIVE

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Interviews with facility staff indicated discrepancies regarding whether the wound was open or not. On June 1, 2020, R1 was seen by R1’s regular physician, who sent R1 to the Emergency Room. Medical records show R1 was admitted to a general acute care hospital on June 1, 2020 and diagnosed with Pressure injury of skin of sacral region, unspecified injury stage, Abscess perirectal and Decubitus ulcer of back, stage 4. R1 underwent a surgical debridement and cultures were taken, one or both of R1’s wounds were found to be infected with three (3) microbes - Proteus, MRSA, and Bacteroides. Interview with the hospital’s Wound Care Director indicated that R1’s injury 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 hospital on June 1, 2020 and did not return to the facility. R1 was admitted to hospice care on June 17, 2020 and expired on June 25, 2020. R1’s death certificate indicated that R1’s cause of death was “Sepsis,” with a secondary cause of death listed as “Sacral Decubitus Ulcer.” The local County Sheriff’s Office investigation is still open and pending.

Based on observation, records review, and interviews, the facility did not seek timely medical attention for R1’s pressure wounds which resulted in R1’s death. R1’s immediate cause of death was sepsis (according to the Mayo clinic, “sepsis is a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues. When the infection-fighting processes turn on the body, they cause organs to function poorly and abnormally. Sepsis may progress to septic shock. This is a dramatic drop in blood pressure that can lead to severe organ problems and death”). R1’s secondary cause of death was documented as sacral decubitus ulcer (according to National Pressure Injury Advisory Panel, Pressure Injuries are defined as: localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.).

** Report continued on 809-C **

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: VINSON'S CARE HOME	FACILITY NUMBER: 340310728
	VISIT DATE: 08/27/2021

NARRATIVE

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At the time of the complaint visit on March 19, 2021, an immediate civil penalty for $500 was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

Today 8/27/2021, the Department will be issuing a civil penalty per Health and Safety code § 1569.49 in the amount of $15,000 for a violation that the Department determines resulted in the death of R1. However, since an immediate civil penalty of $500 was issued on March 19, 2020, the amount today will be $14,500.

A copy of the LIC 421D was given to Licensee and originals were signed.

Exit interview conducted. Appeal Rights provided. A copy of the report issued. Licensee's signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC809 (FAS) - (06/04)

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