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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881005
Report Date: 10/27/2023
Date Signed: 10/27/2023 12:09:39 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2023 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230927120232
FACILITY NAME:A AND E LOVING SENIOR HOME CARE, INC.FACILITY NUMBER:
361881005
ADMINISTRATOR:BERNARDO, RUSSELLFACILITY TYPE:
740
ADDRESS:14931 OAKSPRING DRIVETELEPHONE:
(909) 320-7888
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: 4DATE:
10/27/2023
ANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee/Administrator Evafe Green - Sosnovsky and Administrator Russel BernardoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff left resident in a soiled diaper for a long period of time causing resident to develop wounds.
INVESTIGATION FINDINGS:
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On 10/27/2023 at 11:00 AM, Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Evafe Green - Sosnovsky and Administrator Russel Bernardo at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegation. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates that Staff left resident in a soiled diaper for a long period of time causing resident to develop wounds. LPA Brown obtained evidence to corroborate the allegation above. Interview with Resident #2 (R2) indicated staffs are changing their diapers one (1) in the morning and one (1) at bedtime. Resident #3 (R3) reported to LPA Brown that staff are chaning their diapers one (1) in the morning, one (1) at lunch and one (1) at bedtime and Resident #4 (R4) indicated that staffs are changing their diapers two (2) or three (3) times per day. ***Continuation on LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
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 56-AS-20230927120232
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
, CA 92507
FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005
VISIT DATE: 10/27/2023
NARRATIVE
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However, interviews with R4 revealed that staffs are not changing their diaper at nighttime and R4 reported to LPA Brown "If I'm wet or I dirty my diaper at night, I have to wait until the morning to be changed and the most recent date this happened was three (3) weeks ago." Also, interviews with R2 and R3 indicated that staff are changing their diapers during the day and at bedtime and R2 and R3 did not report that staff at the facility are checking or changing their diaper at nighttime. Interviews with Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3) indicated that no resident was left with a soiled diaper for a long period of time causing resident to develop wounds. LPA Brown asked if the facility has a record of their residents’ incontinent care and S1, S2 and S3 reported to LPA Brown that no such records exist. LPA Brown requested a copy of Care Notes/Progress Notes for their residents and S1, S2 and S3 revealed they do not have Care Notes/Progress Notes for their residents. Moreover, LPA Brown observed staff inconsistent report as to how often staff at the facility checked on their residents and change their diaper. Also, during the visit on 10/23/2023, LPA Brown requested the facility's Personnel Summary (LIC500) from S2 and LPA Brown observed that no staff are scheduled to work on a night (NOC) shift and immediately address the issue with S2. S2 updated the facility's LIC500 showing S2 as staff coverage on NOC shift.

Furthermore, staff interviews with S1, S2 and S3 indicated something described as R1's scratching behavior that resulted to a wound on R1's buttocks was observed on 06/2023. S1, S2 and S3 confirmed with LPA Brown that they did not seek medical assistance regarding this observation. S1 and S2 reported to LPA Brown that they reported the incident to R1's responsible party but failed to report to R1's primary physician. Interview with S3 revealed that they treated the wound with hydrocortisone and moisturizer provided by R1's responsible party.

Investigation revealed that on 09/28/2023, R1 was admitted for Hospice Care and upon admission, medical records show that R1 was diagnosed with Stage 2 Pressure Ulcer of left buttocks.

Based on LPA Brown's investigation, it is concluded that there is sufficient evidence to substantiate allegation of Staff left resident in a soiled diaper for a long period of time causing resident to develop wounds.
It was evident that R1 required staff assistance with activities of daily living, including incontinent care. However, it was found that facility staff failed to provide the services needed by R1 to meet R1 needs. As a result, R1 sustained Stage 2 Pressure Ulcer of left buttocks while in care. ***Continuation in LIC9099C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20230927120232
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
, CA 92507
FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005
VISIT DATE: 10/27/2023
NARRATIVE
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A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where this report (LIC9099), LIC9099D and Appeal Rights were discussed, and a copy was provided to Licensee/Administrator Evafe Green - Sosnovsky and Administrator Russel Bernardo at the conclusion of the visit.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20230927120232
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
, CA 92507

FACILITY NAME: A AND E LOVING SENIOR HOME CARE, INC.
FACILITY NUMBER: 361881005
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2(a) Additional Personal Rights of Residents in Privately Operated Facilities: ...Residents in privately operated RCFEs shall have all of the following...rights: (4)To care, supervision, & services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, & competency to meet their needs. This requirement was not met as evidenced by:

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The licensee stated to train all staff on CCR 87468.2(a)(4) and submit proof of Staff Training Log to LPA Brown at Plan of Correction (POC) due date.
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Based on interviews & records review, it was found that Licensee did not ensure R1 received the care, supervision & services to meet their needs. On 09/28/2023, R1 was admitted for Home Health Service at a community care licensed facility in Laverne and R1 was diagnosed with Stage 2 Pressure Ulcer of left buttock. However, it was found that treatment and care for the injury was not being provided as needed. This violation of regulation posed an immediate health, safety and personal rights 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4