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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425270
Report Date: 05/26/2021
Date Signed: 05/26/2021 06:36:05 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
02/10/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210210162451
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: 160DATE:
05/26/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Administrator MaCriselda Espiritu SantoTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility failed to provide adequate medical treatment.
Facility failed to report an incident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George conducted an unannounced visit to the facility for the purpose of delivering findings for the above allegation(s). LPA George met with Administrator MaCriselda Espiritu Santo. Below is a summary of the investigation.

Allegation facility failed to provide adequate medical treatment.
Based on interviews and records review Resident #1 (R1) had been previously reported that there was an issue two times prior to when R1 actually ended up "passing out/falling" in the front of the medication room, which occurred on 2/6/21. It was determined by the attending physician that R1s blood sugar was 1100. Note that there is not a Doctor's order to check R1s blood sugar. Administrator did state that a request was made, but there was no response given. Additional information from interviews state that R1 had begun making reference to their being a bump on their bottom area and it was bothering/hurting them, about 3 weeks prior to the incident on 2/6/21.


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: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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 3
Control Number 18-AS-20210210162451
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: ABRIA DEL CIELO
FACILITY NUMBER: 366425270
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2021
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, by compliance with the following:
1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
Based on 1 out of 1 resident was not provided assistance with getting their medical needs met. This poses a potential health, safety and personal rights risk to persons in care.
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The licensee agrees to have an inservice on the importance of knowing when to seek medical treatment and the importance of documentation. Proof shall be submitted to the department by 5pm on the due date indicated.
Type B
06/08/2021
Section Cited
CCR
87211(1)(B)
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87211 Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by:
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The licensee agrees to have an inservice on reporting requirements. Proof shall be submitted to the department by 5pm on the due date indicated.
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1 out of 1 incident was not reported to the responsible party. Based on observation, interview and record review this poses a potential health, safety and personal rights risk to person's 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: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210210162451
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: ABRIA DEL CIELO
FACILITY NUMBER: 366425270
VISIT DATE: 05/26/2021
NARRATIVE
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Two weeks prior to the incident R1 shared that they went to the Nurse and nothing was done about the bump, however R1 went back and was then provided an ointment from the Nurse. 1 week prior to the incident on 2/6/21, is when R1 began not eating and not feeling well, which lead to them passing out.

Per documentation reviewed R1 was last having been showered by facility staff on 2/3/21. Due to the location of the "bump" Staff would not have observed the bump. However LPA reviewed additional documentation and there is no mention of anything in R1s file/charts, outside of the ointment that was verbally stated by R1, no medical attention was offered or a Doctor's appointment was scheduled. The allegation of Facility failed to provide adequate medical treatment. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation #2 Facility failed to report an incident.
Based on records review LPA received and reviewed an LIC 624 was processed and stamped in the regional office on the 7th day of when the incident (2/6/21-sending resident out to the hospital) occurred. However, the facility staff called R1's Sibling whom is not the responsible party. The responsible party is the Public Guardian as R1 is conserved. R1s Conservator did not become aware of the incident until the RN from the hospital placed the call. Therefore the allegation of Facility failed to report an incident. 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 exit interview was conducted and a copy of this report, 9099C, 9099D and appeal rights was provided to Administrator MaCriselda Espirtu Santo.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3