374601634-2-9-2024-08-AS-SJAB-D2PLSR-20240222080107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601634
Report Date: 02/09/2024
Date Signed: 02/09/2024 11:27:54 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
10/30/2020 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20201030135039

FACILITY NAME:	MOUNTAIN VIEW HEALTHCARE		FACILITY NUMBER:	374601634
ADMINISTRATOR:	SONYA KARPAL		FACILITY TYPE:	740
ADDRESS:	1404 JAMACHA ROAD		TELEPHONE:	(619) 588-8045
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92019
CAPACITY:	0	CENSUS: 0	DATE:	02/09/2024
		UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Report Mailed to Licensee via USPS Certified Mail		TIME COMPLETED:	09:02 AM

ALLEGATION(S):

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Staff neglect lead resident to sustain a pressure injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Pena sent this report to former licensee's last known mailing address via USPS certified mail.

On October 30, 2020, Community Care Licensing (CCL) received a complaint alleging the facility neglected a resident which resulted in the resident sustaining a pressure injury. The Department’s investigation consisted of LPA observation, interviews with pertinent residents, staff and outside sources, and facility and outside source record reviews.

Records reviewed indicate Resident 1 (R1) lived at the facility from 6/20/20 through 10/27/20. R1’s Physician's Report dated 6/20/20 revealed a dementia diagnosis with no observed skin issues. R1’s Pre-placement appraisal dated 6/20/20 also noted no skin issues. R1’s records noted R1 began receiving home health services on 8/07/20 for a diabetic foot ulcer and non-pressure left heel ulcer. Records also indicate R1’s mental status declined which exacerbated encephalopathy and dementia.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

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 3

Control Number 08-AS-20201030135039

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MOUNTAIN VIEW HEALTHCARE	FACILITY NUMBER: 374601634
	VISIT DATE: 02/09/2024

NARRATIVE

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On 9/11/20 and 9/15/20, R1 displayed an inability to follow instructions regarding their physical therapy and was discharged due to lack of follow through between sessions. R1 also became a two-person transfer. On 10/02/20, it was noted that R1’s blister and wounds had improved and were healing. Notes reflect home health care personnel provided facility staff education on hydration and diet.

Based on a review of the home health care documents did not indicate the presence of a care plan as outlined in 87609 Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s).

LPA obtained copies directly from R1’s home health care because the facility did not have a plan of care on file. The facility’s home health care document retained had limited information and did not delineate a care plan for physical therapy that the resident was receiving, or the wound care for the blister.

The Department’s investigation revealed that R1 underwent a change in condition (skin breakdown), but the licensee did not conduct an appropriate reappraisal, and did not have an appropriate home health plan on file at the facility to address R1’s diabetic foot ulcer. Resident had a blister on the left heel that turned into a stage three pressure injury after diagnosis at the hospital wound care department. Per home health care notes, Licensee signed off on R1’s plan of care - acknowledging understanding what care facility staff was to provide (however, licensee did not retain a copy). Records showed that R1 was discharged from physical therapy due to their dementia diagnosis and lack of physical exercises completed outside of physical therapy sessions because the resident was unable to follow directions. According to the notes, the facility only had one staff working at a time and the resident subsequently required a two-person transfer. R1 was admitted on 10/27/20 to the hospital for a UTI/dehydration and transferred to another hospital for wound care on 10/28/20 per R1’s medical records.

Based on the Department’s investigation which consisted of review of pertinent records and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D. A copy of this report and Appeal and Licensee Rights (LIC 9058 03/22) were provided to the former Licensee, via USPS Certified Mail.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20201030135039

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MOUNTAIN VIEW HEALTHCARE	FACILITY NUMBER: 374601634
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/07/2024 Section Cited HSC 1569.49	1 2 3 4 5 6 7	ASSISTANCE WITH ACCESSING HOME HEALTH OR HOSPICE SERVICES; RECEIPT OF MEDICAL SERVICES - Failure to meet or arrange to meet the needs of those residents who require health-related services as specified in the resident’s written record of care...is a	1 2 3 4 5 6 7	Immediate health and safety risk was removed as facility closed as of February 7, 2024. Plan of correction cleared.
	8 9 10 11 12 13 14	licensing violation and subject to civil penalty pursuant to Section 1569.49. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure the written record of care identified by the home health agency for one 1 of 6 residents was followed. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC9099 (FAS) - (06/04)

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