366412117-8-18-2023-18-AS-KCLS-CV7UVA-20230830155445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366412117
Report Date: 08/18/2023
Date Signed: 08/18/2023 01:16:00 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
08/21/2020 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 18-AS-20200821151905

FACILITY NAME:	CAREGIVERS II		FACILITY NUMBER:	366412117
ADMINISTRATOR:	JAEWON KIM		FACILITY TYPE:	740
ADDRESS:	10945 TRENMAR LANE		TELEPHONE:	(909) 877-0850
CITY:	BLOOMINGTON	STATE: CA	ZIP CODE:	92316
CAPACITY:	6	CENSUS: 5	DATE:	08/18/2023
		ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jaewon Kim Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Neglect resulted in resident developing stage 4 pressure injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bernadette Allen met with Jaewon Kim Administrator at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office on 08/18/2023 to deliver the findings for the allegation above.

The Department conducted an investigation into allegation of neglect of R1. The Investigation consisted of records review and interviews with relevant parties.
R1 was admitted to the facility on August 30, 2019. Upon admission R1 was identified as non-ambulatory, with no history of pressure injuries. According to facility records, R1 needed assistance with activities of daily living (ADLs), including toileting needs.

On July 13, 2020, Staff 1 (S1) found R1 on the bedroom floor after hearing a loud noise. It was indicated that R1 had sustained an unwitnessed fall. According to S1, R1 did not have visible injuries nor did R1 complain of pain. R1 was placed back in the bed and S1 notified R1’s responsible party of the incident.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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-20200821151905

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: CAREGIVERS II	FACILITY NUMBER: 366412117
	VISIT DATE: 08/18/2023

NARRATIVE

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Interview with S1 revealed that on July 15, 2020, R1 was observed to have redness which was described as an open pressure “wound” less than 1cm. on R1 buttocks. S1 indicated that from July 15, 2020, through July 23, 2020, the wound worsened. R1 was taken to urgent care by responsible party on July 23, 2020. According to medical records, R1 was diagnosed with Stage 2 pressure ulcer of coccyx. Records indicated treatment to be provided included topical ointment. Investigation did not reveal evidence to support that treatment was provided to R1 as required.

On July 31, 2020, facility documentation revealed that R1 was reported to not want to eat and had pain. It was further indicated that on August 2, 2020, the wound became worse and R1 had pale complexion, displayed lack of eating, had severe constipation, and complained of pain. S1 reported that responsible party was contacted to inform of R1 condition. However, S1 nor facility staff arranged for medical assistance to meet R1 needs. It was not until August 13, 2020, when R1 was transported to the hospital.

R1 was admitted to the hospital on August 13, 2020. Hospital records revealed that R1 was diagnosed with buttock cellulitis, Stage IV pressure ulcer of sacrum with exposed bone, foul odor, severe sepsis with acute organ dysfunction. R1 remained in the hospital for treatment and was later discharged to another location.

Based on the Department investigation, it is concluded that there is sufficient evidence to substantiated allegation of staff neglect of R1. It was evident that facility staff failed to provide the services needed by R1 to meet R1 needs. As a result, R1 sustained a Stage 4 pressure ulcer of sacrum (coccyx) area while in care.

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 Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code 1569.49(f).

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20200821151905

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: CAREGIVERS II	FACILITY NUMBER: 366412117
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/23/2023 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 and are delivered by staff that are sufficient in numbers, qualifications, & competency to meet their needs.	1 2 3 4 5 6 7	The administrator has agreed to have all staff members read the cited regulation and Health and Safety Code 1569.49(f) and provide a signed statement of understanding from all staff members by the POC date 8/23/2023.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews & records review, it was found that from at least July 23, 2020, until August 13, 2020, Licensee did not ensure R1 received the care, supervision & services to meet their needs. R1 was diagnosed with Stage 2 pressure ulcer of coccyx on July 23, 2020. It was determined that treatment and care for the ulcer was not provided as needed. On August 13, R1 was admitted to the hospital and was diagnosed with a Stage 4 pressure ulcer of sacrum with exposed bone, foul odor. This violation of regulation posed an immediate risk to R1.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC9099 (FAS) - (06/04)

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