361880626-10-11-2021-18-AS-JESL-C7YT34-20211020142143

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880626
Report Date: 10/11/2021
Date Signed: 10/11/2021 10:56:27 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/02/2020 and conducted by Evaluator Stephanie Torres

COMPLAINT CONTROL NUMBER: 18-AS-20200102113339

FACILITY NAME:	JCP COTTAGE		FACILITY NUMBER:	361880626
ADMINISTRATOR:	LEE, PATRICK		FACILITY TYPE:	740
ADDRESS:	14241 LA MIRADA ST		TELEPHONE:	(949) 769-9626
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY:	6	CENSUS: 5	DATE:	10/11/2021
		UNANNOUNCED	TIME BEGAN:	10:10 PM
MET WITH:	Frisco Sanry, Licensee		TIME COMPLETED:	11:00 PM

ALLEGATION(S):

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Staff did not ensure facility was maintained at a comfortable temperature
Staff failed to meet resident health needs
Resident sustained stage four pressure injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation on the above allegations. The LPA was greeted by staff, Florencio Munar, and later me with Administrator, Frisco Sanry. Lee was informed of the purpose of the visit.

Pertaining to the allegation, "Staff did not ensure facility was maintained at a comfortable," it was alleged Resident One (R1) was always cold while in care of the facility. The Department commenced the investigation of the allegation on January 08, 2020. At time of visit it was revealed R1 passed away on October 24, 2019 and so an interview could not be conducted. Resident interviews were conducted though unsuccessful; due to resident cognitive decline, information could not be obtained. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time.

With regard to the allegation, "Staff failed to meet resident health needs," it was alleged Residents One (R1) and Two (R2) were not turned regularly by staff members. Prior to the commencement of the investigation it

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

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 18-AS-20200102113339

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: JCP COTTAGE	FACILITY NUMBER: 361880626
	VISIT DATE: 10/11/2021

NARRATIVE

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was revealed R1 and R2 had passed away and so interviews could not be conducted. Hospice medical records were obtained for each resident. Records show neither residents were diagnosed with pressure injuries; however, staff were instructed to reposition/turn both residents regularly. R1's medical records indicate red skin noted to their coccyx. Daily notes were reviewed for each resident. Notes did not indicate R1 was or was not repositioned/turned regularly. Resident interviews were conducted though unsuccessful; due to resident cognitive decline, information could not be obtained. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

With regard to the allegation, "Resident sustained stage four pressure injury while in care." it was alleged Resident Three (R3) sustained a stage four (4) pressure injury while in care of the facility. Prior to the completion of the investigation it was revealed R3 had passed away and so an interview could not be conducted. Medical records were obtained; an Interdisciplinary Plan of Care Update/Meeting revealed R3 was receiving hospice services for a stage II pressure injury to their Coccyx. R3's records revealed the resident was hospitalized on November 22, 2019 and diagnosed with a stage III to IV sacral decubitus ulcer prior to discharge. R3's Hospice notes reveal the initial injury was a result of incontinence and poor eating. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

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 violations occurred.

An exit interview was conducted with Sanry, in which this report was reviewed and a copy provided.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

LIC9099 (FAS) - (06/04)

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