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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004960
Report Date: 06/09/2020
Date Signed: 06/09/2020 10:17:27 AM



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
01/24/2020 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200124114800
FACILITY NAME:EASTERN MANORFACILITY NUMBER:
347004960
ADMINISTRATOR:APUYA, MARIAFACILITY TYPE:
740
ADDRESS:2629 EASTERN AVENUETELEPHONE:
(916) 972-9668
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:13CENSUS: 10DATE:
06/09/2020
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria Apuya, Administrator TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Facility staff failed to seek timely medical attention for resident
INVESTIGATION FINDINGS:
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On 6/9/2020, the Department (CCLD) concluded a complaint investigation received on 01/24/2020 which alleged that facility staff failed to seek timely medical attention for resident. Licensing Program Analyst (LPA) Calzada arrived unannounced at approximately 9:30 am and met with Maria Apyua, Administrator/Director, and explained purpose of inspection.

During the investigation, the Department interviewed the facility Director, multiple staff and residents and reviewed documentation including, but not limited to, residents (R1) physician report, care plan, facility incident report, hospital medical records, home health medical records, and emergency responder notes.

The results of the investigation are as follows:

Per the emergency responder's report dated 1/16/2020, they responded to a facility call that resident was experiencing hip pain. The report indicates that facility staff had observed resident to have hip pain for the last two weeks but it appeared worse on 1/16/2020. Staff was interviewed during
cont on 9099C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2020
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 5
Control Number 27-AS-20200124114800
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: EASTERN MANOR
FACILITY NUMBER: 347004960
VISIT DATE: 06/09/2020
NARRATIVE
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the investigation regarding why medical attention for resident was not sought prior to 1/16/2020. Staff indicated that when they asked the resident if they were in pain when they appeared to be, while holding their stomach, resident would touch their stomach. Staff believed that resident was experiencing pain due to the Urinary Tract Infection (UTI) diagnosed on 12/31/19 that they were recovering from and did not seek additional medical attention. Facility Home Health records do not indicate that facility staff reported that resident was experiencing hip pain or weakness. Resident was admitted to the hospital on 1/16/2020 for further evaluation and then transferred and admitted to a skilled nursing facility on from 1/20/2020 due to a fractured pelvis. Resident returned to the facility on 1/27/2020 and was placed on hospice in February.

Per the death report completed by the facility, the resident passed on 4/9/2020 from degeneration of the brain. The county death certificate notes the cause of death as Alzheimer's Disease and lists Hypertension as a contributing factor. Resident was on hospice when they passed.

Based on the information obtained, LPA finds the above allegation 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 deficiency was cited on 9099-D, per Title 22 Regulations, Division 6, Chapter 8. Failure to correct the deficiency by the noted due date may result in a penalty(ies) being assessed.

Exit interview. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20200124114800
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: EASTERN MANOR
FACILITY NUMBER: 347004960
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2020
Section Cited
CCR
87705(b)(1)
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87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes. This requirement is not met as evidenced by:

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Licensee/Administrator agrees to conduct staff training on timely reporting to physicians, family, responsible person as required and review Regulation 87705. Documentation of agenda and attendees to be provided by fax to CCL by 6/23/2020.
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Based on interviews conducted and documentation reviewed, the facility did not ensure that resident (R1) received timely medical attention after observing resident to be in pain in the stomach area, which 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: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/24/2020 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200124114800

FACILITY NAME:EASTERN MANORFACILITY NUMBER:
347004960
ADMINISTRATOR:APUYA, MARIAFACILITY TYPE:
740
ADDRESS:2629 EASTERN AVENUETELEPHONE:
(916) 972-9668
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:13CENSUS: DATE:
06/09/2020
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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9
Facility staff failed to provide adequate supervsion which resulted in resident sustaining a pelvis fracture.
INVESTIGATION FINDINGS:
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On 6/9/2020, the Department (CCLD) concluded a complaint investigation received on 01/24/2020 which alleged that facility staff failed to provide adequate supervision which resulted in resident sustaining a pelvis fracture. Licensing Program Analyst (LPA) Calzada arrived unannounced at approximately 9:30 am and met with Maria Apyua, Administrator/Director, and explained purpose of inspection.

During the investigation, the Department interviewed the facility Director, multiple staff and residents and reviewed documentation including, but not limited to, residents (R1) physician report, care plan, facility incident report, hospital medical records, home health medical records.

The results of the investigation are as follows:

On 1/16/2020, resident (R1) was sent out to the ER due to complaining of hip pain and lower stomach pain and was diagnosed with a hip fracture. Medical records indicate that resident sustained a fractured pelvis as a result of a fall and that the fall may have been unwitnessed and not communicated to facility staff due to resident having a diagnosis of Dementia and being non-verbal. An interview conducted with a physician could not definitively confirm that the injury was a result of the fall. Facility staff deny that resident had a fall and there was no documentation on file noting a fall for resident. Facility was unable to explain how resident could have sustained the injury; however, confirmed that resident required assistance when being transferred.
cont on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2020
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 5
Control Number 27-AS-20200124114800
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: EASTERN MANOR
FACILITY NUMBER: 347004960
VISIT DATE: 06/09/2020
NARRATIVE
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Facility staff indicated that resident was not a fall risk; however, Home Health records, dated 1/8/2020, indicate resident was a fall risk but do not have any supporting documentation that the facility reported to them that resident had hip pain or weakness. The death report submitted by the facility indicates that resident passed away on 4/9/2020 due to degeneration of the brain. The county death certificate notes the cause of death as Alzheimer's Disease and Hypertension as a contributing factor. Resident was on hospice when they passed. Based on the investigation conducted, it is unclear how resident sustained the fractured pelvis.

LPA finds the above allegation to be UNSUBSTANTIATED- A finding that the complaint 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.

There are no deficiencies per Title 22 Regulations, Division 6, Chapter 8 being cited.

Exit interview. Copy of report provided to Administrator.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5