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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880786
Report Date: 02/01/2021
Date Signed: 02/17/2021 09:29:38 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
07/22/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200722091219
FACILITY NAME:SOMERFORD PLACE-REDLANDSFACILITY NUMBER:
361880786
ADMINISTRATOR:TURNER, DANICA JFACILITY TYPE:
740
ADDRESS:1319 BROOKSIDE AVENUETELEPHONE:
(617) 796-8350
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:75CENSUS: 37DATE:
02/01/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Danica TurnerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable death.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Stephanie Williams contacted the facility in order to deliver findings for the above allegation via telephone due to the ongoing COVID-19 pandemic. LPA identified herself and discussed the purpose of the call with Administrator, Danica Turner. The department investigation included facility file review, interviews with staff/residents/witnesses, and reviewing pertinent records, including medical records.

Department staff investigated the allegation of the questionable death of Resident #1 (R1) caused by neglect from the facility's staff. According to medical records, on 6/18/2020, R1 was admitted to the hospital. R1's diagnosis was determined to be sepsis secondary to pneumonia. R1 was placed on palliative care on 6/19/2020 and subsequently passed away on 6/20/2020.

R1's cause of death was determined to be severe sepsis and healthcare associated pneumonia. Dehydration was among several other subsequent conditions contributing to death not resulting in the underlying cause. According to medical records for R1, from January to June of 2020, R1’s primary care physician did not
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
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 4
Control Number 18-AS-20200722091219
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: SOMERFORD PLACE-REDLANDS
FACILITY NUMBER: 361880786
VISIT DATE: 02/01/2021
NARRATIVE
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document any signs of sepsis or dehydration during tele-health visits of this time frame. R1’s primary care physician documented R1’s general appearance as “well nourished.” Department staff interviewed hospital's attending physician who stated that R1’s condition could have been “immediate” and facility staff could not have known R1 was septic. Hospital physician also reported that facility staff sent R1 to the hospital “soon” after R1’s “sudden change” in condition. Interviews with other pertinent individuals did not reveal evidence to support questionable death or neglect by the facility.

As a result of investigation, the department has found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted where this report was discussed and a copy was provided to Turner via email.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
LIC9099 (FAS) - (06/04)
Page: 1 of 2
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
07/22/2020 and conducted by Evaluator Stephanie Williams
COMPLAINT CONTROL NUMBER: 18-AS-20200722091219

FACILITY NAME:SOMERFORD PLACE-REDLANDSFACILITY NUMBER:
361880786
ADMINISTRATOR:TURNER, DANICA JFACILITY TYPE:
740
ADDRESS:1319 BROOKSIDE AVENUETELEPHONE:
(617) 796-8350
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:75CENSUS: DATE:
02/01/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Danica TurnerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident developed pressure injuries while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Stephanie Williams contacted the facility in order to deliver findings for the above allegation via telephone due to the ongoing COVID-19 pandemic. LPA identified herself and disccused the purpose of the call with Administrator, Danica Turner. The department investigation included facility file review, interviews with staff/residents/witnesses, and reviewing pertinent records, including medical records.

According to Resident #1's (R1's) medical records, R1 developed a pressure injury which was reported to R1's primary care physician by the facility on 6/15/2020. The physician referred R1 for home health services; however, services were discontinued as facility staff were educated on applying topical ointment to treat Stage II pressure injury. According to R1's medical records, there appeared to be no documentation of neglect by the facility staff to cause the pressure injuries. Although resident developed pressure injury, it could not be determined that it developed due to staff neglect.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
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 2
Control Number 18-AS-20200722091219
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: SOMERFORD PLACE-REDLANDS
FACILITY NUMBER: 361880786
VISIT DATE: 02/01/2021
NARRATIVE
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7
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document any signs of sepsis or dehydration during tele-health visits of this time frame. R1’s primary care physician documented R1’s general appearance as “well nourished.” Department staff interviewed hospital's attending physician who stated that R1’s condition could have been “immediate” and facility staff could not have known R1 was septic. Hospital physician also reported that facility staff sent R1 to the hospital “soon” after R1’s “sudden change” in condition. Interviews with other pertinent individuals did not reveal evidence to support questionable death or neglect by the facility.

As a result of investigation, the department has found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted where this report was discussed and a copy was provided to Turner via email.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/22/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200722091219

FACILITY NAME:SOMERFORD PLACE-REDLANDSFACILITY NUMBER:
361880786
ADMINISTRATOR:TURNER, DANICA JFACILITY TYPE:
740
ADDRESS:1319 BROOKSIDE AVENUETELEPHONE:
(617) 796-8350
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:75CENSUS: 37DATE:
02/01/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Danica TurnerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident developed pressure injuries while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Stephanie Williams contacted the facility in order to deliver findings for the above allegation via telephone due to the ongoing COVID-19 pandemic. LPA identified herself and discussed the purpose of the call with Administrator, Danica Turner. The department investigation included facility file review, interviews with staff/residents/witnesses, and reviewing pertinent records, including medical records.

According to Resident #1's (R1's) medical records, R1 developed a pressure injury which was reported to R1's primary care physician by the facility on 6/15/2020. The physician referred R1 for home health services; however, services were discontinued by physician. Facility staff were educated on applying topical ointment to treat Stage II pressure injury. According to R1's medical records, there appeared to be no documentation of neglect by the facility staff to cause the pressure injuries. Although resident developed pressure injury, it could not be determined that it developed due to staff neglect.

Based on evidence obtained during the investigation, LPA has determined that the above allegation is
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20200722091219
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: SOMERFORD PLACE-REDLANDS
FACILITY NUMBER: 361880786
VISIT DATE: 02/01/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
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14
15
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UNSUBSTANTIATED; meaning that 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 where this report was discussed and a copy was provided to Turner via email.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4