366426751-7-1-2021-18-AS-RLAY-C4PMC7-20210707092900

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426751
Report Date: 07/01/2021
Date Signed: 07/01/2021 09:30:33 AM

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
07/09/2020 and conducted by Evaluator Pauline Beschorner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200709102128

FACILITY NAME:	EVANS ELDERLY RESIDENTIAL CARE		FACILITY NUMBER:	366426751
ADMINISTRATOR:	EVANS, KELLY		FACILITY TYPE:	740
ADDRESS:	13947 CASTILLE ST.		TELEPHONE:	(760) 261-4241
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY:	6	CENSUS: 2	DATE:	07/01/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Kelly Evans		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff neglect resulting in resident developing stage 3 or 4 pressure injury resulting in death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pauline Beschorner conducted an unannounced visit to the facility to deliver findings regarding the allegation mentioned above. LPA met with Licensee/Administrator Kelly Evans. The investigation included a review of resident 1’s (R1) medical records, and interviews with medical professionals.

The allegation was that staff neglect resulted in resident developing stage 3 or 4 pressure injury resulting in death. A review of R1’s medical records and staff notes revealed conflicting and vague information about the stage of R1’s pressure injury prior to admittance and upon discharge. None of the medical documentation received from the facility or from hospice lists the stage of the pressure injury on R1. Medical records first indicated that R1 had a pressure injury on March 5, 2020. R1 was ordered respite care from March 19, 2020 to March 24, 2020. On March 26, 2020 medical records indicated R1’s pressure injury had a foul smell but that the pressure injury was unstageable.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

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-20200709102128

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: EVANS ELDERLY RESIDENTIAL CARE	FACILITY NUMBER: 366426751
	VISIT DATE: 07/01/2021

NARRATIVE

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Based upon the investigation, the progression of the pressure injury is unclear. The investigation revealed facility staff cared for R1’s pressure injury. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. 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, and a copy of this report, and appeal rights, were reviewed with and provided to Licensee/Administrator Kelly Evans, whose signature on this form confirm receipt of the above-mentioned documents.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC9099 (FAS) - (06/04)

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