374600890-4-27-2022-08-AS-SJAB-CDXW22-20220429165337

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600890
Report Date: 04/27/2022
Date Signed: 04/27/2022 08:19:14 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
03/12/2020 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20200312094050

FACILITY NAME:	ATRIA COLLWOOD		FACILITY NUMBER:	374600890
ADMINISTRATOR:	KRXZYSZTOF WALUSZKO		FACILITY TYPE:	740
ADDRESS:	5308 MONROE AVE		TELEPHONE:	(619) 286-3583
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	185	CENSUS: 86	DATE:	04/27/2022
		UNANNOUNCED	TIME BEGAN:	03:10 PM
MET WITH:	Executive Director, Julia Lopez		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff failed to address scabies issue.
Staff failed to address resident's change in medical condition.
Staff failed to provide appropriate transportation for resident.
Staff failed to provide appropriate transportation for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegations, LPA was met and granted entry into the facility by Executive Director (ED) Julia Lopez to whom was explained the purpose for the visit.

The Department's investigation consisted of facility staff and outside source interviews, as well as facility, resident, and medical record reviews.

It was alleged facility staff failed to address Resident’s1 (R1's) case of scabies. In May of 2019 a facility record review revealed R1 developed a rash and was being treated with a steroid cream for Dermatitis. A review of medical records corroborated R1 was receiving treatment for Dermatitis, the records also revealed the treatment was administered through the end of July 2019. Further review of medical records, as well as a interview with an outside source (OS1) revealed R1’s rash was misdiagnosed. OS1 revealed requesting facility staff to have R1's rash re-evaluated to no avail. OS1 took it upon themselves to coordinate and transport R1 to see a dermatologist at the end of July of 2019 that resulted in R1's rash being re-diagnosed as scabies. A review of R1’s resident record revealed on July 31, 2019 OS1 notified facility staff about R1's diagnosis of scabies and facility staff implemented universal precautions per the community protocol.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

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-20200312094050

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: ATRIA COLLWOOD	FACILITY NUMBER: 374600890
	VISIT DATE: 04/27/2022

NARRATIVE

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It was also alleged facility staff failed to address resident's change in medical condition. An interview with OS1 also revealed R1 had been showing signs of illness for approximately 6 months and facility staff never contacted the Responsible Party or a physician, nor did they attempt to coordinate a medical assessment. The interview also revealed it was not until OS1 coordinated an appointment with a medical professional themselves that R1 was seen and diagnosed with Pneumonia and a UTI. A medical record review revealed R1 was seen by a mobile medical agency approximately twice a month. Review of medical records did not indicate a diagnosis of Pneumonia or a UTI. A facility and resident record review also revealed no documentation regarding R1 receiving a diagnosis of Pneumonia or UTI.

It was alleged facility staff failed to provide R1 transportation for to medical appointments as listed in the Admission Agreement. An interview with OS1 revealed facility staff would not allow R1 access to the facility bus for transporting residents to their medical appointments, nor did they help arrange an appointment for R1 to see a dermatologist. An interview with another outside source (OS2) corroborated the facility would not allow R1 on the facility bus. An interview with another outside source (OS3) was able to corroborate OS1 arranged and provided transportation to the Dermatologist appointment that resulted in the accurate diagnosis of scabies. The facility staff was unable to provide any documentation regarding transportation for R1’s medical appointments to refute the allegation.

It was also alleged facility staff failed to properly reappraise resident while in care. Based on a resident record review R1’s Admission Agreement revealed R1 was assessed at a care level of ‘0’ and also a ‘0’ level of care for medication management. The level of care scale ranges from 0 through 4, 0 being the lowest and 4 being the highest level of care. A review of facility records dated May 31, 2018 revealed R1 was documented at a personal (assistance with ADL’s) care level of 1 and a medical care level of 2. Further review of records indicated R1 received five assessments between facility admission and December 27, 2018 indicating R1 began receiving assistance with showering as od March 23, 2019, staff also began administering ointment for R1's skin condition, and also implementing universal precautions to mitigate the spread of scabies, at that time R1’s level of medical care was bumped to a level three and then returned to a level two once the scabies had been eradicated. Facility staff was unable to provide documentation of including or notifying R1's Responsible Party of changes in R1's level of care.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200312094050

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: ATRIA COLLWOOD	FACILITY NUMBER: 374600890
	VISIT DATE: 04/27/2022

NARRATIVE

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Due to lack of corroborating evidence, the finding regarding the above allegations were established to be unsubstantiated. This finding means although the allegations may have happened, or could be valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted with ED Lopez and a copy of the Complaint Investigation Report (LIC 9099) and Licensee Rights (LIC 9058 01-2016) was provided to ED Lopez, and signature on this report acknowledges receipt of the reports.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

LIC9099 (FAS) - (06/04)

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