366426756-9-12-2023-18-AS-JDHS-CVZSE3-20230925134800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426756
Report Date: 09/12/2023
Date Signed: 09/12/2023 10:02:57 AM

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
06/18/2020 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200618145329

FACILITY NAME:	CARING TEAM HOME CARE		FACILITY NUMBER:	366426756
ADMINISTRATOR:	CLEMONS, NORA		FACILITY TYPE:	740
ADDRESS:	9736 11TH AVE.		TELEPHONE:	(760) 998-2108
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY:	6	CENSUS: 5	DATE:	09/12/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Nora Clemons, Licensee		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Staff neglect resulted in a resident sustaining multiple pressure injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility for the purpose of delivering findings for the above allegation. LPA George met with Licensee Nora Clemons and explained the purpose of visit.

The above allegation was investigated by the department. The investigation consisted of interviews and obtaining documentation that includes: a review of the facility's complaint history, Special Incident Reports (SIR), resident's medical records, and hospice records.

Resident #1 (R1) was admitted to the facility in or around May 2016 and was not noted to have any pressure injuries, nor to be bed bound upon their admission to the facility based on interview with licensee. Licensee reported R1 became bedridden the last three (3) months of their life. R1 passed away on 08/11/2020. R1 was still able to sit up in bed but was unable to sit up in a wheelchair. *** Continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (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)

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Control Number 18-AS-20200618145329

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: CARING TEAM HOME CARE	FACILITY NUMBER: 366426756
	VISIT DATE: 09/12/2023

NARRATIVE

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The Licensee observed redness to R1’s back in May of 2020 and began treating R1 with an ointment. This treatment by the licensee was conducted prior to consultation with the doctor and prior to contacting hospice. Interviews conducted with multiple facility staff, corroborated the Licensee was tending to the wounds using an ointment. The licensee reported facility staff used and treated the red areas with ointment (skin barrier cream or A&D ointment) for an estimated time period of two weeks.

Between May of 2020 and June 6, 2020, the pressure injuries were not diagnosed by a physician or appropriately skilled professional. Neither did R1 receive care for the pressure injuries from a physician or appropriately skilled professional. The licensee reported acting in good faith but confirmed she is not a physician nor a skilled professional able to treat the pressure injuries.

R1 was not admitted to hospice until June 6, 2020. Per R1’s hospice admission paperwork R1 was “bed bound” and had a history of reoccurring pressure injuries to their sacral area (space between coccyx and spine). At the time of R1’s hospice admission, they were assessed and noted to have “six (6) to seven (7)” pressure injuries ranging from stage II to unstageable. This was noted on the admission paperwork dated June 6, 2020. The pressure injuries were observed to be on R1’s shoulder, arm, back, and sacral area. As a result of the confirmed pressure injuries, facility staff were instructed by hospice staff, to turn R1 every 2 hours.

Based interviews and record reviews, the allegation of Staff neglect resulted in a resident sustaining multiple pressure injuries 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.

Based on the findings of the investigation deficiencies were observed in the areas evaluated and cited according to California Code of Regulations, Title 22, Division 6 and listed on the LIC 9099D. 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, and a copy of this report, 9099C, 9099D, immediate civil penalty assessment and appeal rights were provided to Licensee Nora Clemons.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (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)

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Control Number 18-AS-20200618145329

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: CARING TEAM HOME CARE	FACILITY NUMBER: 366426756
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/26/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	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	1 2 3 4 5 6 7	The Licensee agrees to conduct an inservice on body checks and sign breakdown. Proof of completed POC is to be submitted to to the department by 5pm on the due date indicated.
	8 9 10 11 12 13 14	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: The Licensee failed to take the necessary steps for a proper medical assessment for R1. Posed a potential health risk to persons in care.	8 9 10 11 12 13 14
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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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (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)

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