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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425270
Report Date: 09/12/2023
Date Signed: 09/12/2023 12:37:19 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/21/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210621113522
FACILITY NAME:ABRIA DEL CIELOFACILITY NUMBER:
366425270
ADMINISTRATOR:CRISELDA ESPIRITU SANTOFACILITY TYPE:
740
ADDRESS:1589 N. WATERMAN AVETELEPHONE:
(909) 884-4757
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY:240CENSUS: 143DATE:
09/12/2023
UNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Administrator Macriselda Espiritu SantoTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident sustained pressure injuries while in care due to neglect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to deliver findings for the allegation mentioned above. LPA met with Administrator Criselda Espirtu Santo and explained the purpose of the visit. The investigation consisted of interviews, and records review.

Resident sustained pressure injuries while in care due to neglect.
It was alleged that Resident #1 (R1) sustained a Stage 4 pressure injury while resident was in care of Abria Del Cielo. R1 was admitted on 02/02/2018 and was discharged on 12/29/2020. R1 was placed at the facility under the Assisted Living Waiver (ALW) program. An ALW assessment plan dated 06/02/2020 revealed R1 was incontinent of both bladder and bowels. A goal of the plan was to have an absence of skin breakdown. Per R1’s Physician’s Report dated 02/02/2018, R1 required assistance with dressing, bathing, and toileting.
A review of medical records dated 07/25/2020, revealed that on 07/26/2020, R1 had redness on their coccyx area and a scab of a healed pressure injury on their left foot. R1 was sent to a skilled nursing facility (SNF) for wound care on 07/31/2020. *** Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
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 5
Control Number 18-AS-20210621113522
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: ABRIA DEL CIELO
FACILITY NUMBER: 366425270
VISIT DATE: 09/12/2023
NARRATIVE
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Per the SNF Discharge Summary dated 08/31/2020, R1 was discharged back to the facility on 08/31/2020 with instructions to assist R1 in setting up Home Health. Home Health was needed for the following services: physical therapy, occupational therapy, Registered Nurse (RN) and Home Health Aide (HHA). Per an interview with the Assistant Living Coordinator Kevin Villacorte, the facility did not assist R1 with obtaining home health services as instructed. R1 was discharged from the facility on 09/23/2020 for needing a higher level of care, according to staff interviews. R1 was transferred to a SNF on 09/23/2020. Per the Skin Assessment dated 09/30/2020, completed upon R1’s admission to the SNF, R1 was noted to have an unstageable pressure injury on their coccyx area. It is noted that “the coccyx pressure injury had so much slough” (according to Oxford English Dictionary, slough is defined as “a layer or mass of dead tissue or flesh formed on the surface of a wound, sore, …”) “and eschar” (according to Oxford English Dictionary, eschar is defined as “a brown or black dry slough, resulting from the destruction of a living part, …”), “that it could not be staged until it was opened and examined.” Hospital nurse assessed the pressure injury and reported it was estimated that the time for the pressure injury to reach the unstageable stage “was approximately weeks”.

Interview with Licensed Vocational Nurse (LVN) working at the facility revealed, she was aware of the beginning stages of a pressure ulcer on R1’s coccyx area. She provided instructions to caregivers to monitor R1, rotate R1 every two hours and to provide a cream. LVN further revealed R1 was not receiving wound care. Staff interview revealed if a resident develops redness, they do not call the hospital or SNF. It is the facility’s policy that if a pressure injury is not healing, they will then send the resident out for treatment. The investigation did not reveal that R1 was sent out for treatment between 08/31/2020 and 09/23/2020. Interviews with 4 facility staff revealed, staff either denied seeing any redness or denied seeing anything worse than redness on R1.

Therefore, based on interviews and record reviews, the allegation of Resident sustained pressure injuries while in care due to neglect is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being assessed. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.

An exit interview was conducted, a copy of this report was reviewed and provided along with the 9099C, 9099D, appeal rights, and LIC421IM was given to Administrator Macriselda Espiritu Santo.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/21/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210621113522

FACILITY NAME:ABRIA DEL CIELOFACILITY NUMBER:
366425270
ADMINISTRATOR:CRISELDA ESPIRITU SANTOFACILITY TYPE:
740
ADDRESS:1589 N. WATERMAN AVETELEPHONE:
(909) 884-4757
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY:240CENSUS: 143DATE:
09/12/2023
UNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Administrator Macriselda Espiritu SantoTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff left resident in soiled adult brief.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to deliver findings for the allegation mentioned above. LPA met with Administrator Criselda Espirtu Santo and explained the purpose of the visit. The investigation consisted of interviews, and records review.

Per R1’s Physician’s report dated 02/02/2018, R1 required assistance with their ADLs such as dressing, bathing, and toileting. R1 was placed at the facility under the Assisted Living Waiver (ALW) program. The ALW assessment plan date 06/02/2020, revealed that R1 was incontinent of both their bladder and bowels. A goal of the plan was to have an absence of skin breakdown. Interviews conducted with facility staff revealed that R1 was repositioned and assisted with their toileting needs, however the facility does not keep a toileting or repositioning log. Staff interviews revealed that during waking hours (time R1 wakes up, until they go to sleep), R1 is changed and repositioned every two hours or in between if R1 calls for assistance. During sleeping hours, R1 calls for assistance as they need, for their adult brief to be changed throughout the night. Interviews revealed R1’s sleeping hours would be from about 10pm to 7am.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20210621113522
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: ABRIA DEL CIELO
FACILITY NUMBER: 366425270
VISIT DATE: 09/12/2023
NARRATIVE
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Not all relevant parties could be interviewed during the course of the investigation. There is insufficient evidence to corroborate or refute the allegation of Staff left resident in soiled adult brief, therefore the allegation is UNSUBSTANTIATED at this time. 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 violation did or did not occur.

An exit interview was conducted, a copy of this report was reviewed and provided along with the 9099C, was given to Administrator Macriselda Espiritu Santo.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20210621113522
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: ABRIA DEL CIELO
FACILITY NUMBER: 366425270
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/26/2023
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and dental care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care... (1) The licensee shall arrange or assist in
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The Licensee agrees to conduct an inservice on skin breakdown, skin interity issues and body checks. Proof of POC is to be submitted to to the department by 5pm on the due date indicated.
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arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: The Licensee failed to follow the doctors orders and assist R1 with getting home health. This posed a potential health, safety and personal rights risk to persons in care.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5