374600732-1-17-2023-08-AS-LTEZ-CNM2G3-20230131162227

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600732
Report Date: 01/17/2023
Date Signed: 01/17/2023 03:19:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/05/2021 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20211005085957

FACILITY NAME:	CARMONA'S RESIDENTIAL CARE		FACILITY NUMBER:	374600732
ADMINISTRATOR:	MARY ANNE MARTINEZ		FACILITY TYPE:	740
ADDRESS:	3427 BEAGLE PLACE		TELEPHONE:	(858) 277-6731
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92111
CAPACITY:	6	CENSUS: 6	DATE:	01/17/2023
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Caregiver Milagros "Mila" Caganap		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Resident sustained unexplained bruising while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint investigation visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Milagros "Mila" Caganap.

During today's visit, LPA observed residents in care and interviewed staff.

The Department’s investigation consisted of interviews with staff and outside sources, review of records, and a tour of the facility. It was alleged that a resident sustained unexplained bruising while in care. Review of resident 1’s (R1) medical records dated March 24, 2020, revealed that R1 had major cognitive disorder, was non-ambulatory, and was able to follow direction and communicate needs. Medical records revealed that R1 began receiving hospice services in June 2021.

Continued on LIC9099-C page...

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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 08-AS-20211005085957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARMONA'S RESIDENTIAL CARE	FACILITY NUMBER: 374600732
	VISIT DATE: 01/17/2023

NARRATIVE

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Interviews and review of hospice care notes revealed that during a hospice care visit, hospice staff observed small bruises on R1’s left jaw and back in September 2021, and healing bruises on R1’s left eye and left jaw, and a small bruise on R1’s left forearm in October 2021. Interviews revealed that facility staff were not aware of the bruises observed in September 2021, and denied hitting or causing R1’s bruising. Interviews and hospice care notes revealed that a care conference was conducted to discuss R1’s bruising between facility staff, the Licensee, R1’s family, and hospice staff in October 2021. Interviews revealed that R1’s family stated that R1 could have obtained the bruises by moving around in the bed and hitting the bed rails. The Licensee stated that R1’s sedative medication was not working and R1 was banging their head against the bed rails. Interviews revealed that facility staff were not administering R1’s sedative medications as prescribed due to concerns that R1 would be overly sedated. Hospice staff provided staff with education regarding administering medication as prescribed and padding was placed over the bed rails to prevent further bruising during the care conference in October 2021. Interviews with outside sources did not reveal any concerns regarding R1’s care. Interviews with skilled medical professionals revealed that bruising was possible after an episode of agitation and hitting against the bed rails. Review of hospice care notes revealed that no new bruising was observed after October 2021. The Department was unable to interview R1 due to R1 passing away.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Caregiver Mila Caganap, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

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