374600708-6-22-2023-08-AS-DPOL-CTAPT5-20230630113521

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600708
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:43:22 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2021 and conducted by Evaluator Carmen Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20211228080115

FACILITY NAME:	LILAC CHATEAU II		FACILITY NUMBER:	374600708
ADMINISTRATOR:	KIMBERLY WITHERS		FACILITY TYPE:	740
ADDRESS:	9724 EUCALYPTUS COURT		TELEPHONE:	(619) 449-6187
CITY:	SANTEE	STATE: CA	ZIP CODE:	92071
CAPACITY:	0	CENSUS: 0	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Closed Facility - Report sent via USPS Certified Mail		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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- Unlawful Eviction.
- Resident sustained pressure injury due to lack of care.
- Staff did not administer resident’s medication as prescribed.
- Staff did not seek medical attention for resident after change of condition.
- Staff did not follow resident’s prescribed diet.
- Staff did not meet resident’s assessed care needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Carmen Lopez sent this report to the Licensee's last known mailing address, via USPS certified mail, to deliver the investigation findings for the above listed allegations. The facility changed ownership on 6/15/22.

The Department’s investigation consisted of interviews with staff and outside sources, and records review of relevant documents pertinent to this investigation. On 12/28/ 2021, it was alleged that the facility unlawfully evicted a resident; resident sustained a pressure injury due to lack of care; staff did not administer medication as prescribed; staff did not seek medical attention for resident after change in condition; staff did not follow resident’s prescribed diet; and staff did not meet resident’s assessed care needs.

It was specifically alleged that the facility was retaliating against resident #1 (R1) and provided R1 with an eviction notice. Review of records revealed a written eviction notice dated 12/22/21, was provided to R1’s responsible party (RP) with an effective date of 12/26/21.
(Continuation on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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 4

Control Number 08-AS-20211228080115

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILAC CHATEAU II	FACILITY NUMBER: 374600708
	VISIT DATE: 06/22/2023

NARRATIVE

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This would not have been a valid or lawful eviction; however, the notice was not enforced or reviewed by the Department. Interview with an outside source said it was a “moot point” because the facility did not evict R1. Staff interviews confirmed that R1 remained at the facility through the Change of Ownership until the family decided to voluntarily move R1 out. Based on staff and outside source interviews, there is insufficient evident to support the allegation of an unlawful eviction.

It was specifically alleged that R1 sustained a pressure injury due to staff not turning the resident. Interview with an outside source said that R1 was not being turned every two hours; however, it was not known if turning R1 was indicated that in R1’s Primary Care Physician (PCP) notes. Interview with staff did not know or recall when R1 sustained the pressure injury. According to staff, R1 had a scar where the pressure injury was located but was unknown if R1 had previously had a pressure injury. Staff said when Home Health (HH) was initiated, they were trained by the HH nurse to treat the pressure injury. An interview with Home Health staff confirmed they began services on 9/13/21 to treat the pressure injury. According to the HH agency, R1 was well taken care of, and the superficial pressure injury had healed quickly. HH was able to determine the care the facility provided due to how quickly the pressure injury healed, which indicated R1 was repositioned as required during this time. HH did not express any concerns with the services the facility provided to R1 with pressure injury care. Interview with an outside source revealed that R1’s RP took care of arranging and providing medical appointments for R1. Outside source said the facility notified R1’s RP on 8/08/21, that they noticed R1 had a “sore” on 8/07/21, and R1 was admitted to HH on 9/13/21. Review of R1’s Physician Report showed R1 required continuous bed care but did not provide a specific explanation. It also indicated that R1 was non-ambulatory and unable to transfer to and from bed. Review of Needs and Service Plan (LIC625), dated 3/29/21, R1 needed assistance with all activities of daily living (ADL’s) but did not mention repositioning or turning. Based on the evidence obtained, there is insufficient evidence to support the allegation.

It was specifically alleged, on 12/28/21, that the resident was prescribed a medication by their PCP, but the medication had not been filled since March 2021. Interview with an outside source said that the facility did not provide R1s Polyethylene Glycol (stool softener) as prescribed. They said that it took the facility 5 months to request R1’s medication, which was long lasting. Outside source said that when they spoke with the Licensee, Licensee confirmed they had told staff not to provide R1 with the stool softener medication daily. Interview with staff said that they recalled either Licensee or S1 preparing the medications in the mornings, and they would give R1 their medication throughout the day as indicated. They did not recall which medications were provided to R1.
(Continuation on LIC 9099-C)

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20211228080115

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILAC CHATEAU II	FACILITY NUMBER: 374600708
	VISIT DATE: 06/22/2023

NARRATIVE

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Interview with S1, did not recall the medications provided to R1, but recalled preparing the medications in the mornings for the upcoming shifts. S1 said that the staff on the assigned shifts would initial the Medication Administration Record (MAR) to show that they provided the medication to R1. Interviews with Licensee said that they did not have a copy of the MAR as they shred the MAR monthly when the residents new cycle begins for confidentiality purposes. A review of staff records revealed that staff were trained on medication throughout the year, 2021. An outside photo was submitted to the Department and according to the outside source, the photo was taken on 09/07/21, and the facility had requested for that routine medication to be filled six months later, on 9/09/21. According to the medication bottle, the medication was filled on 3/21/21, but the photo was not dated. Based on the information obtained, there is insufficient evidence to support the allegation.

It was specifically alleged that the staff did not make necessary arrangements after resident sustained a pressure injury around mid-July, early August. Interview with an outside source revealed that R1’s responsible party (RP) took care of medical appointments for R1. The facility notified R1’s RP on 8/08/21, that they noticed R1 had a small pressure injury on 8/07/21; According to the outside source, R1 was admitted to HH on 9/13/21. When R1 was admitted to HH, staff were also provided training by the HH agency on how to dress the pressure injury and keep it clean. Staff were unaware who was responsible for assisting residents to make medical appointments. An interview with a Home Health Agency said that they were initiated by R1s RP to address the pressure injury. According to the agency, they did not have any concerns with the services the facility provided to R1 with wound care. According to the facility R1s charting notes, on 9/13/21, a HH agency went to visit R1 to address the stage 2 pressure injury. Staff was to monitor and notify. Admission Agreement for R1 showed that extra charges for optional health care services were offered to the RP but showed that the services were not paid for or included by the RP. Optional Services were exhibited in the admission agreement and included assistance with necessary medical and dental needs. Based on the information obtained during staff and outside source interviews, and review of records including outside source records, there is insufficient evidence to support the allegation.

It was specifically alleged that staff served resident seafood on 12/03/2021, although staff should have been aware of the resident’s allergies and their dietary restrictions. A review of R1’s Physician’s Report (LIC602), dated 3/29/21, reported that the resident was allergic to shellfish derived products, and required a diabetic diet. The Preplacement Appraisal Information (LIC603), dated 4/10/21, described R1’s dietary limitations as able to eat chopped fine foods, no fish and fish products.
(Continuation on LIC9099-C)

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20211228080115

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: LILAC CHATEAU II	FACILITY NUMBER: 374600708
	VISIT DATE: 06/22/2023

NARRATIVE

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Residents Appraisal (LIC603A), dated 4/10/21, described R1’s diet to be chopped fine/mechanical soft diet. A review of the facility menu revealed that they had seafood on the menu, but also had an alternative option that was not seafood based. A review of facility report dated 11/18/21, revealed that facility Administrator provided staff with training which included diet, safety and care due to concerns family brought forth. Interview with an outside source said staff attempted to serve R1 pancit (noodles) with shrimp; however, R1 did not eat the meal as the outside source did not allow R1 to eat the meal. Interviews with staff confirmed that they were aware of R1’s allergies. Staff recalled the incident and confirmed that R1 was not served shrimp. A staff person had cooked the shrimp but did not plan to serve that to R1, who was offered pancit with chicken. Based on the information obtained during staff and outside source interviews, and records reviewed, there is insufficient evidence to support the allegation that staff did not follow the resident’s prescribed diet.

It was specifically alleged that R1 was left by staff unresponsive in the dining area for an extended period of time. Interview with outside source said that they went to visit R1 and upon entrance R1 was unresponsive, slouched and with their head slanted to the side. Outside source said that staff shook R1 for a reaction and R1 began to vomit. R1 was taken to the hospital for further evaluation. Interviews with staff confirmed the incident, but staff said that R1 would at times become tired after meals and tended to fall asleep in their wheelchair. Review of records confirmed the facility self-reported the incident, dated 12/03/21, to the Department. They reported that R1 had a decreased level of consciousness and vomited undigested food. Staff called 911 and R1 was taken to the hospital. R1’s medical evaluation determined resident had a urinary tract infection and returned to the facility that same day with prescribed antibiotics. Additional facility health notes, dated 12/04/23, revealed that staff was present in the dining area with residents, then walked over to answer the door. Based on the information obtained during staff and outside source interviews, and records reviewed, there is insufficient evidence to support the allegation that staff did not meet R1’s assessed care needs.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside sources interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated.

Due to the facility’s closure, no exit interview was conducted. Copies of this report and Licensee Rights (LIC 9058) were mailed via USPS certified mail to the last mailing address on file.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

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