361880660-6-22-2020-18-AS-JESL-BR3VDA-20200630162026

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880660
Report Date: 06/19/2020
Date Signed: 06/22/2020 02:37:03 PM

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
05/13/2020 and conducted by Evaluator Crystal Colvin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200513095740

FACILITY NAME:	RIALTO ASSISTED LIVING		FACILITY NUMBER:	361880660
ADMINISTRATOR:	KYONG SUK LEE		FACILITY TYPE:	740
ADDRESS:	1441 S RIVERSIDE AVE		TELEPHONE:	(909) 877-2340
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	94	CENSUS: 52	DATE:	06/19/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Janet Oliver - Marketing Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff abandoned resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Crystal Colvin contacted the facility via telephone to deliver findings on an open complaint investigation via telephone due to COVID-19. LPA identified herself and discussed the purpose of the call and the elements of the allegation with Marketing Director Janet Oliver. Below is a summary of the findings of the investigation:

Regarding allegation "Facility staff abandoned resident": LPA Colvin interviewed numerous parties and outside agencies, including staff from the facility, Kasier Permanente and Charter Home Health; reviewed medical records from the facility, Kasier Permanente and Charter Home Health regarding the resident (R1), who is the subject of this complaint. On 5/8/20, facility staff contacted paramedics and law enforcement in order to seek emergency medical treatment for R1, who's medical condition was worsening, as she had been consistently refusing any medical treatment or aid from the facility or Home Health. Law Enforcement placed R1 on a 51/50 psychiatric hold for Grave Disability, and the resident was taken to the hospital and later transferred to Kaiser Permenente for further treatment.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2020

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-20200513095740

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: RIALTO ASSISTED LIVING	FACILITY NUMBER: 361880660
	VISIT DATE: 06/19/2020

NARRATIVE

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Once R1 was at Kaiser and Kaiser reached out to the facility for discharge planning, the facility staff informed Kaiser that they would not be able to take the resident back upon discharge from the hospital, as they were unable to meet her needs, even with the addition of Home Health.

Earlier this year, in February, R1 was hospitalized due to developing a severe rash with an infection, which required medical intervention and treatment at Kaiser Hospital. The rash had developed due to R1 refusing to shower or accept assistance from the facility with bathing. During this first hospitalization, the facility originally denied accepting the resident back, as they recognized that they could not meet her needs, but they eventually agreed to readmit her after a brief time in a medical rehabilitation facility, with the addition of Home Health. Shortly after the resident was readmitted to the facility in March 2020, the facility began running into barriers with caring for R1, such as R1's Power of Attorney (POA) not providing the facility with the resident's prescription ointment, which was needed for the rash that the resident had been hospitalized for. The facility contacted R1's POA to request the medication but were unsuccessful in getting the POA to deliver it to the facility. The facility refrained from picking up the resident's medication initially, as it needed to be paid for and the resident had no personal funds at the facility, and an outstanding balance at another pharmacy for over $100. After two weeks of the resident not being able to have the prescription ointment applied due to the facility not having the medication, one of the facility staff members went to the pharmacy and paid out of their own pocket for the medication.

Though now the facility had all the medication for R1, they continued to hit hurdle after hurdle with R1's care, as R1 began refusing to shower again and refuse staff assistance. In addition to refusing basic hygiene, R1 refused wound treatment from Home Health and facility staff frequently, as well as refusing to take oral medications. During this time, the facility kept in communication with Community Care Licensing (CCL), as well as reach out to any other agency they could to request help, such as Public Guardian, Adult Protective Services, Kasier Permanente, and R1's POA, as in accordance with Title 22 Regulation section 87466, Observation of the Resident. Eventually, R1's rash began to worsen again and spread to other areas of the body. The facility staff reached out to Home Health to advise of their plan to contact the paramedics to seek emergency assistance for R1, but Home Health wanted to make another attempt with their Registered Nurse (RN) to assess R1 and evaluate their need for medical care. On 5/8/20, the RN from Home Health came to the facility and witnessed R1's combative state, wherein they were unable to even assess R1's vital signs. The facility staff and the RN agreed to have the paramedics called, and R1 was ultimately taken to the hospital for treatment of the rash, which was again at risk for infection.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2020

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200513095740

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: RIALTO ASSISTED LIVING	FACILITY NUMBER: 361880660
	VISIT DATE: 06/19/2020

NARRATIVE

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Typically, when a facility has a resident sent out to the hospital, they remain responsible for the resident and are expected to readmit the resident back into the facility once they are discharged from the hospital. However, in this unusual case, the facility acknowledged that they are unable to care for R1 and meet their needs, and therefore could not accept R1 back into the facility without risking R1's health again. Title 22 Regulations section 87611(e), General Requirements for Allowable Health Conditions, states that the facility shall ensure that a resident is cared for according to physician's orders, and that the resident's needs are met. Since the facility had reason to believe that they would not be able to meet the needs of the resident, their denial of accepting R1 back into the facility was justified, as the resident was at risk of bodily harm, should they return to the facility where the staff are unable to meet R1's needs. Additionally, prior to R1's hospitalization, the facility attempted to relocate R1 to a more suitable placement, as evidenced by the eviction notice they provided to R1 and their POA on 4/3/20, wherein the facility notes that they are unable to care for the resident due to the resident's refusal of treatment and the facility's lack of necessary supplies provided by the POA (such as diapers and medication).

The facility had identified back during R1's initial hospitalization in February 2020 that they were unable to meet R1's needs, but decided to try again with the assistance of Home Health, as the resident had been living at the facility for many years and it was considered her home. Since R1's second and most recent hospitalization in May 2020, the facility has realized that they cannot care of R1's needs even with the assistance of Home Health, and therefore cannot accept R1 back into the facility in good conscience. In fact, Health and Safety Code 1569.725(a)(1) states that a facility may only be allowed to have Home Health assist a resident with care so long as the resident's needs are being met through the combination of Home Health and the facility's staff. R1's time at the facility from March 2020 to May 2020, wherein Home Health was a feature in R1's plan of care, demonstrates R1's needs were beyond what the facility and Home Health could care for. It was stated by multiple individuals involved with R1's care that were interviewed that it is clear that R1 needs a higher level of care than what is available at the facility. Due to record review and interviews conducted, the above allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Marketing Director Janet Oliver via telephone and a copy of this report was provided to Janet Oliver and Administrator Clara via email. Report with facility representative signature was obtained.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2020

LIC9099 (FAS) - (06/04)

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