361880893-9-2-2022-18-AS-DMUN-CJRSXS-20220930141625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880893
Report Date: 05/18/2022
Date Signed: 09/02/2022 02:17:01 PM

Substantiated

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
07/31/2020 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200731095043

FACILITY NAME:	PACIFICA SENIOR LIVING HILLSBOROUGH		FACILITY NUMBER:	361880893
ADMINISTRATOR:	TAYLOR, MANDY		FACILITY TYPE:	740
ADDRESS:	11918 CENTRAL AVENUE		TELEPHONE:	(909) 548-2100
CITY:	CHINO	STATE: CA	ZIP CODE:	91710
CAPACITY:	156	CENSUS: 111	DATE:	05/18/2022
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Jennifer Heldoorn, Executive Director		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Staff neglect resulted in resident #1 (R1) sustaining an infected pressure injury (ulcer).

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, visited the facility to deliver the investigative findings. The LPA identified herself and discussed the purpose of the visit with Executive Director (ED), Jennifer Heldoorn.

The Department conducted investigation into allegation of neglect of R1. The Investigation consisted of records review and interviews with relevant parties.

Per medical records, R1 was admitted to the hospital on July 26, 2020 due to change in breathing. Review of medical records revealed that on July 26, 2020, a physical exam was conducted which showed that R1 had various conditions including a Sacral Decubitus Ulcer Stage III infected 4cm by 3 cm foul smelling with discharge.

According to the investigation, facility records indicate that on July 8, 2020, facility staff observed a pressure injury to R1, located on coccyx area. The facility staff notified R1's Home Health agency on July 9, 2020. On

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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-20200731095043

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PACIFICA SENIOR LIVING HILLSBOROUGH	FACILITY NUMBER: 361880893
	VISIT DATE: 05/18/2022

NARRATIVE

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July 16, 2020, a physician authorized treatment to the injury by home health agency. However, when home health staff visited the facility on same day, to evaluate R1, they were denied entry by a facility staff member. On July 23, 2020, home health staff visited facility again and assessed the pressure injury to be a Stage III.

From time period from at least July 8, 2020 to July 26, 2020, it was found that R1 was not provided the care and services needed to meet R1 needs. Review of facility records revealed that R1 utilized a wheelchair for ambulation and needed assistance with incontinent care. According to R1 care plan, R1 had “impaired skin integrity” and “resident needs to be changed every 2 hours to prevent skin breakdown which meets the need for every 2 hour status checks.” Staff interviews revealed that R1 remained in bed majority of the time and was not rotated while in bed. Interviews also revealed that R1 was observed in soiled incontinence briefs on several different occasions. Investigation also revealed that facility staff was unable to obtain documentation that illustrated correspondence between the facility and home health agency to support that a plan of care for treatment of the pressure injury was in place and/or being followed. Furthermore, interviews confirmed that R1 had history of pressure ulcers and was recently discharged from home health treatment on May 21, 2020 following the healing of a previous ulcer.

Based upon investigation, the preponderance of the evidence standard has been met, therefore the allegation that staff neglect resulted in resident #1 (R1) sustaining an infected pressure injury (ulcer) is substantiated. Evidence supports that R1 had a pressure injury and facility staff neglected to insure care and services was provided and/or was received to meet R1 needs.

An immediate civil penalty of $500 is assessed. The Executive Director was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(f).

An exit interview was conducted; this report was reviewed with Heldoorn and a copy was provided, along with LIC 811, LIC 421IM and Appeal Rights.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200731095043

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PACIFICA SENIOR LIVING HILLSBOROUGH	FACILITY NUMBER: 361880893
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/20/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities: ...Residents in privately operated RCFEs shall have all of the following...rights: To care, supervision, & services that meet their individual needs & are delivered by staff that are sufficient in numbers, qualifications, & competency to meet their	1 2 3 4 5 6 7	The Executive Director agreed to provide proof of in-service training to all memory care staff relating to the facility's policy on assisting residents who are bedridden.
	8 9 10 11 12 13 14	needs. This requirement was not met as evidenced by: Based on interviews & records review, it was found that from at least 07/08/20 until 07/26/20, Licensee did not ensure R1 received the care, supervision & services to meet their needs. R1 was observed to have a pressure injury (continued on right)	8 9 10 11 12 13 14	(continued from left) on 07/08/20, but it was found that treatment & care for the injury was not provided as needed. On 07/26/20, R1 was admitted to the hospital & was DX with an infected sacral pressure injury (ulcer) Stage III. This violation of regulation posed an immediate risk to R1.
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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: Deborah Mullen	TELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

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