366404041-10-28-2021-18-AS-JESL-C992TG-20211129164043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366404041
Report Date: 10/28/2021
Date Signed: 10/28/2021 12:41:31 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
03/24/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200324194548

FACILITY NAME:	SANTA FE TRAIL ASSISTED LIVING CENTER		FACILITY NUMBER:	366404041
ADMINISTRATOR:	MICHAEL GARCIA		FACILITY TYPE:	740
ADDRESS:	55425 SANTA FE TRAIL		TELEPHONE:	(760) 365-0887
CITY:	YUCCA VALLEY	STATE: CA	ZIP CODE:	92284
CAPACITY:	0	CENSUS: 0	DATE:	10/28/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator Michael Garcia		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff failed to meet residents needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George visited the facility for the purpose of delivering findings for the above allegation. LPA George met with Administrator Michael Garcia and advised the purpose of visit. Below is a summary of the findings of the investigation: The above allegation was investigated by the department. The investigation consisted of interviews, obtaining pertinent documentation that includes but not limited to a review of the facility's complaint history and Special Incidents Reports (SIRs).

The department received a complaint that resident #1 (R1) sustained a total of two falls February 10, 2020 and February 23, 2020. On February 10, 2020 R1 had a fall that was witnessed by staff. Facility followed protocol and contacted R1s hospice agency. R1 had a cut to the back of the head, hospice responded and provided treatment for the injury. On 2/23/20 R1 sustained an unwitnessed fall. Staff overheard what sounded like an oxygen tank falling and responded to R1’s room. Upon entering R1s room staff observed R1 sitting on the floor with blood coming from the back of R1s head. Hospice was contacted and recommended returning R1 to bed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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-20200324194548

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: SANTA FE TRAIL ASSISTED LIVING CENTER	FACILITY NUMBER: 366404041
	VISIT DATE: 10/28/2021

NARRATIVE

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Facility staff began to clean R1s cut, when R1 began to complain of head pain. Facility staff contacted Hospice again which is when the facility was instructed to contact 911 and have R1 transported to the emergency room. R1 sustained a cut on the left side of the head that required staples, as well as a broken hip. On February 23, 2020 staff present were interviewed who stated that they had completed a body check an hour and a half prior to the fall. According to facility documentation, It is the facility’s practice to check on residents every two hours. Interviewed staff also note that R1 normally sleeps through the night. Documentation reviewed revealed in January 2020 hospice had assessed R1 as a fall risk. Hospice requested to have facility staff remain in close proximity for and when ambulating to have a one-to-one person assist for R1. Note that the time of the incident was reported to have occurred at 4:00am.

Based on interview and record review the allegation of Staff failed to meet resident’s needs is UNSUBSTANTIATED. A finding that the complaint is 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, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted and a copy of this report was provided to Administrator Michael Garcia.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC9099 (FAS) - (06/04)

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