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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700525
Report Date: 07/10/2020
Date Signed: 07/10/2020 12:37:08 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
02/24/2020 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200224125743
FACILITY NAME:ALMOND HEIGHTSFACILITY NUMBER:
342700525
ADMINISTRATOR:AGUIAR, TERRIFACILITY TYPE:
740
ADDRESS:8685 GREENBACK LNTELEPHONE:
(916) 542-7988
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:145CENSUS: 117DATE:
07/10/2020
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Terri Aguiar, Executive DirectorTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Residents left in soiled diapers for an extended period of time.
Facility has an insufficient amount of staff to meet the residents' needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wolter contacted the facility on 07/10/2020 to deliver findings for a complaint Community Care Licensing (CCL) received on 02/24/2020 via telephone due to COVID-19 and pre-cautionary measures, LPA spoke with Executive Director (ED) Terri Aguiar and explained the purpose of the call.

Throughout the course of the investigation CCL reviewed documentation and conducted interviews regarding the allegations: facility has insufficient amount of staff to meet the residents’ needs and residents left in soiled diapers for an extended period of time. Complaint alleged that from November 2019 to the time the complaint was filed on 02/24/2020 the facility continued having these issues ensuring residents needs were met. End of shift notes from October 2019 – December 2019 revealed that residents were found in soiled depends and missed showers due to staffing shortages.

report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
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 8
Control Number 27-AS-20200224125743
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: ALMOND HEIGHTS
FACILITY NUMBER: 342700525
VISIT DATE: 07/10/2020
NARRATIVE
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Throughout the course of the investigation staff indicated concerns to CCL and stated management was informed about not having enough caregivers during each shift to meet the needs of the residents. Staff indicated that because they are short-staffed they are unable to provide proper care to the residents. Staff reported that they postpone showering the residents and providing basic hygiene because they are busy supervising the residents and do not have time during their shift to complete these tasks. When questioned about conducting safety checks, repositioning the residents, and providing incontinence care every two hours, staff reported they do the best they can. They stated they do not have a schedule or log to document this type of care. Staff reported that they try to ensure these tasks are done every two hours, but it gets difficult because they are short staffed.

Facility was previously cited on 04/02/2020 for residents not receiving hygiene care in a timely manner, their plan of correction was received by the due date and cleared, the facility was to create a shower schedule which is filled out after showers are completed and to create a schedule for incontinent residents to ensure they are changed at regular intervals, a log of changes was to be kept and filed. During interviews with staff throughout the course of the investigation CCL was told by ED that prior to April the facility was not keeping logs of adult brief changes; S3 told CCL that it is not documented each time a resident is changed; S4 told CCL that there is no way to track adult brief changes but they trust staff are doing it. No adult brief change logs were provided to CCL for review.

Due to this information CCL finds the allegations to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6.


87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds.

Report continued on LIC 9099-C

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20200224125743
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: ALMOND HEIGHTS
FACILITY NUMBER: 342700525
VISIT DATE: 07/10/2020
NARRATIVE
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The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

87625 Managed Incontinence
(a) The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances: (1) The condition can be managed with any of the following: (C) A program of scheduled toileting at regular intervals.

Exit interview conducted. Copy of report and appeal rights sent to the facility via e-mail, Executive Director to sign and return a copy to Community Care Licensing either by fax or email, a copy should be retained for facility records as well.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
02/24/2020 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200224125743

FACILITY NAME:ALMOND HEIGHTSFACILITY NUMBER:
342700525
ADMINISTRATOR:AGUIAR, TERRIFACILITY TYPE:
740
ADDRESS:8685 GREENBACK LNTELEPHONE:
(916) 542-7988
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:145CENSUS: DATE:
07/10/2020
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Terri Aguiar, Executive DirectorTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Facility staff did not seek medical attention for residents in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wolter contacted the facility on 07/10/2020 to deliver findings for a complaint Community Care Licensing (CCL) received on 02/24/2020 via telephone due to COVID-19 and pre-cautionary measures, LPA spoke with Executive Director (ED) Terri Aguiar and explained the purpose of the call.

Throughout the course of the investigation CCL reviewed documentation and conducted interviews regarding the allegation: Facility staff did not seek medical attention for residents in a timely manner. Complaint alleged that R3 did not received timely medical attention after an unwitnessed fall. Documents reviewed and staff interviews indicated that R3 had an unwitnessed fall the morning of 02/22/2020. No medical attention was sought at the time of the fall, R3 did not have obvious injuries and did not complain of pain, R3 was assisted by dining staff up and was able to use their walker to ambulate.

Report continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 27-AS-20200224125743
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: ALMOND HEIGHTS
FACILITY NUMBER: 342700525
VISIT DATE: 07/10/2020
NARRATIVE
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The PM shift did not notice a swollen ankle but did provide R3 with a pain medication as they complained of pain to their ankle. On 02/23/2020 R3 had another unwitnessed fall during the NOC shift and and was observed on the floor of their bedroom crawling to the bathroom. NOC shift staff noted that R3 had a swollen ankle and was sent to the emergency room. NOC shift staff stated that they did not observe changes in R3’s condition prior to the unwitnessed fall. The investigation was unable to determine when R3 sustained the ankle injury.

Due to this information the department finds the allegation to be UNSUBSTANTIATED - A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Copy of report sent to the facility via e-mail, Executive Director to sign and return a copy to Community Care Licensing either by fax or email, a copy should be retained for facility records as well.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
02/24/2020 and conducted by Evaluator Danyle Wolter
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200224125743

FACILITY NAME:ALMOND HEIGHTSFACILITY NUMBER:
342700525
ADMINISTRATOR:AGUIAR, TERRIFACILITY TYPE:
740
ADDRESS:8685 GREENBACK LNTELEPHONE:
(916) 542-7988
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:145CENSUS: DATE:
07/10/2020
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Terri Aguiar, Executive DirectorTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Residents developed wounds due to neglect from facility staff.
Resident sustained injury due to fall resulting from lack of care and supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wolter contacted the facility on 07/10/2020 to deliver findings for a complaint Community Care Licensing (CCL) received on 02/24/2020 via telephone due to COVID-19 and pre-cautionary measures, LPA spoke with Executive Director (ED) Terri Aguiar and explained the purpose of the call.

Throughout the course of the investigation CCL reviewed documentation and conducted interviews regarding the allegations: Residents developed wounds due to neglect from facility staff and resident sustained injury due to fall resulting from lack of care and supervision. Complaint alleged that R1 and R2 had pressure wounds due to neglect from facility staff. Hospice notes were reviewed, and it was determined that R1 was not diagnosed with a pressure wound, interviews with hospice nurse and facility staff did not indicate that there was neglect from the staff which caused R1’s condition to worsen.

Report continued on LIC 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20200224125743
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: ALMOND HEIGHTS
FACILITY NUMBER: 342700525
VISIT DATE: 07/10/2020
NARRATIVE
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Hospice notes reviewed for R2 indicate that R2 was diagnosed with a stage 2 pressure injury and hospice provided care for the wound, interviews with hospice nurse and facility staff did not indicate that there was neglect from the staff which caused R2’s condition to worsen. Complaint alleged that R3 sustained an injury after an unwitnessed fall due to lack of care and supervision. Documents reviewed revealed that R3 sustained a foot fracture after an unwitnessed fall. Staff told CCL that R3 had an unwitnessed fall the morning of 02/22/2020 and was assisted by dining staff up and was able to use their walker to ambulate, on 02/23/2020 R3 had another unwitnessed fall during the NOC shift and presented with a swollen ankle, R3 was sent to the ER where they were diagnosed with a foot fracture. A facility assessment dated 12/12/2019 indicated that R3 was able to transfer and ambulate independently with or without an assistive device.

Due to this information the department finds the allegations UNFOUNDED. A finding that the allegations are unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. Copy of report sent to the facility via e-mail, Executive Director to sign and return a copy to Community Care Licensing either by fax or email, a copy should be retained for facility records as well.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20200224125743
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: ALMOND HEIGHTS
FACILITY NUMBER: 342700525
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2020
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required [...]
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The licensee will submit a plan of how staff levels will be maintained to ensure that residents needs are met at all times. Licensee to create, utilize, and retain a document that ensures residents are being observed regularly to ensure their needs are met. Licensee to send these completed records weekly to CCL for minimum of three months.
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This requirement was not met as evidenced by: interviews and document review. The licensee failed to comply with the regulation referenced above. Documents reviewed and interviews with staff reveal that staff was not sufficient in numbers to meet the needs of residents. This poses a potential health and safety risk to residents in care.
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Plan of correction due to CCL by 07/31/2020.

*Repeat Violation, Civil Penalty Assessed*
Type B
07/31/2020
Section Cited
CCR
87625(a)(1)(C)
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87625 Managed Incontinence
(a) The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances: (1) The condition can be managed with any of the following: (C) A program of scheduled toileting at regular intervals.
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Licensee to identify all residents who require incontinence care and create a schedule of toileting at regular intervals. Licensee to ensure all staff is trained on utilizing the schedule. Documentation of scheduled toileting should be kept and retained by the facility.
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This requirement was not met as evidenced by: interviews and document review. The licensee failed to comply with the regulation referenced above. The facility cares for residents who have incontinence needs and a schedule of toileting at regular intervals was not maintained. This poses a potential health and safety risk to residents in care.
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Licensee to send these completed records weekly to CCL for minimum of three months.

Plan of correction due to CCL by 07/31/2020.
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020
LIC9099 (FAS) - (06/04)
Page: 8 of 8