366423474-11-10-2021-18-AS-EMAN-CLN2QM-20221129163611

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366423474
Report Date: 11/10/2021
Date Signed: 11/10/2021 10:58:41 AM

Unsubstantiated

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
10/30/2020 and conducted by Evaluator Natalie Gayoso

COMPLAINT CONTROL NUMBER: 18-AS-20201030144330

FACILITY NAME:	VALLEY CREST		FACILITY NUMBER:	366423474
ADMINISTRATOR:	JORDAN, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	18524 CORWIN RD		TELEPHONE:	(760) 242-3188
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92307
CAPACITY:	65	CENSUS: 33	DATE:	11/10/2021
		UNANNOUNCED	TIME BEGAN:	10:39 AM
MET WITH:	Kimberly Jordan		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident fell multiple times while in care
Resident sustained pressure ulcers while in care
Staff not meeting residents hygiene needs
Staff did not safeguard residents personal belongings
Resident suffered from severe dehydration
Resident was malnourished while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Natalie Gayoso conducted an in office meeting to deliver findingsfor the above allegations with administrator, Kimberly Jordan. LPA introduced herself and explained the purpose of today’s meeting. The investigation consisted of interviews with pertinent parties and records review.
The first allegation indicates resident fell multiple times while in care. Interviews with Staff 1 (S1) stated Resident 1 (R1) had a history of falls and had fallen 3 times while at the facility. Interviews with Staff 2 (S2) and Staff 3 (S3) indicated they were aware that R1 was a fall risk but do not recall R1 ever falling during any of their shifts. S2 stated R1 was consistently being monitored by staff. LPA reviewed Special Incident Reports dated 7/31/2020, 8/12/2020, and 8/17/2020 that stated R1 had unwitnessed falls and was found by staff on the ground. All 3 incident reports indicate staff assessed resident for injuries and contacted Bridge Hospice immediately for assessment. LPA reviewed Bridge Hospice notes that indicate R1 was being monitored by facility staff and hospice staff, and hospice staff did assess R1 after each fall incident.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie Gayoso	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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-20201030144330

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: VALLEY CREST	FACILITY NUMBER: 366423474
	VISIT DATE: 11/10/2021

NARRATIVE

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The second allegation indicates resident sustained pressure ulcers while in care. Interviews with S1 stated R1 was admitted to the facility with a small ulcer on their foot. S2 stated they remember R1 having a pressure ulcer but do not remember if R1 had it before being admitted to the facility or after. LPA review the facility’s Admission Skin Assessment dated 7/24/2020 that indicated a bandage was observed on R1’s left heel and redness above R1’s buttock. Bridge Hospice narrative statement dated 7/15/2020 states R1 had a stage 4 ulcer on left foot. Hospice notes dated 8/17/2020 indicate a pressure ulcer was noted on R1’s coccyx. Hospice notes show wound care was being provided for both ulcers. Interview with Bridge Hospice Regional Director confirmed R1 has a history of ulcers, had an ulcer prior to moving to facility, and was being provided wound care for their foot and buttock.

The third allegation indicates staff not meeting resident’s hygiene needs. Interviews with S1, S2, and S3 indicated R1 would be combative at times when it came to showers and/or shaving, but R1’s hygiene needs were being met. S2 stated they would personally bathe R1 on R1’s scheduled days due to being aggressive with other staff. S2 and S3 state they have never witnessed R1 being kept in dirty soiled clothes. S2, S3, and S4 revealed that staff are not allowed to cut a resident’s hair or nails, staff can only clean and scrub residents nails. S4 indicated only a nurse or skilled professional can cut a resident’s nails. S3 and S4 stated the facility has a hair salon that residents can schedule for a haircut at an additional fee. Interview with Bridge Hospice Regional Director stated bathing, which included shaving and nail filing, was included in R1’s hospice care plan and was done normally on every Monday, Wednesday, and Friday.

The fourth allegation indicates staff did not safeguard resident’s personal belongings. S2, S3, and S4 stated the facility does safeguard resident’s personal belongings. S2 stated R1’s clothing was in their room and had 2 shirts that were donated as backup. S4 has never witnessed any resident wear clothing that is not theirs and residents belongings are label the minute they move into the facility.

The fifth allegation indicates resident suffered from severe dehydration. S2 and S3 stated they have never witnessed R1 suffer from severe dehydration. S3 would make sure R1 would consistently have sips of water. S4 stated there are plenty of water stations throughout the facility for residents to drink. If caregivers notice a resident is not drinking much fluids, they will encourage the resident to drink more water. LPA reviewed hospice notes which did not state R1 was dehydrated. LPA did not observe any medical notes nor lab tests that indicate resident was dehydrated. Interview with Hospice Bridge Regional Director confirmed dehydration was not observed nor notated in any of the hospice notes..

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie Gayoso	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20201030144330

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: VALLEY CREST	FACILITY NUMBER: 366423474
	VISIT DATE: 11/10/2021

NARRATIVE

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The sixth allegation indicates resident was malnourished while in care. Interviews with S2 and S3 stated they have never witnessed R1 be malnourished while at the facility. S2 stated R1’s health stated to decline and needed assistance with eating. LPA reviewed hospice notes that indicated R1 eats approximately 40% or less of child size meal. Hospice nurse also notated R1 had poor appetite or a decrease of appetite on 8/18/20, 8/20/20, 8/25/20, and 8/28/20. LPA did not observe any medical notes nor lab tests that indicate R1 was malnourished. Interview with Hospice Bridge Regional Director confirmed malnourishment was not notated in any of the hospice notes and that it is excepted for residents on hospice to loss weight and not eat nor drink as much as before.

Based on interviews and records review, the above allegations are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cite during this visit.
An exit interview was conducted, and a copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie Gayoso	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

LIC9099 (FAS) - (06/04)

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