374601847-4-2-2021-08-AS-IESA-C2L9MH-20210430232935

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601847
Report Date: 03/19/2021
Date Signed: 04/02/2021 12:40:30 PM

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
10/01/2019 and conducted by Evaluator Evangelica Torres

COMPLAINT CONTROL NUMBER: 08-AS-20191001171112

FACILITY NAME:	SECURE SENIORS		FACILITY NUMBER:	374601847
ADMINISTRATOR:	SANDY KRASOVEC		FACILITY TYPE:	740
ADDRESS:	836 EAGLES NEST GLEN		TELEPHONE:	(760) 746-5123
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY:	16	CENSUS: 16	DATE:	03/19/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Administrator Sandy Krasovec		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff neglect resulted in multiple pressure injuries
Licensee did not arrange medical care for Resident #1

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Eva Torres made an unannounced virtual visit via FaceTime to conclude the investigation and deliver findings. LPA stated the purpose of the visit and spoke with Administrator Sandy Krasovec.

The findings rendered are based on an investigation conducted by the Department. The investigation included a review of facility and medical records, as well as interviews conducted with staff and outside sources.

It was alleged that the licensee did not arrange medical care for Resident #1 (R1) (See LIC 811- Confidential Names List). It was further alleged that staff neglect resulted in multiple pressure injuries.

On December 02, 2018, R1 was admitted into the facility. According to the pre-admission assessment dated December 02, 2018, R1 was ambulatory and required no assistance in toileting, grooming, bathing, and transferring. In addition, R1’s physician’s report dated November 25, 2018, showed that R1 required medication management and was given verbal reminders for bathing.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica Torres	TELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

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-20191001171112

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: SECURE SENIORS	FACILITY NUMBER: 374601847
	VISIT DATE: 03/19/2021

NARRATIVE

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R1’s plan of care dated December 02, 2018, showed the facility provided additional care and supervision in the following areas: social activities, exercising, and monitoring. Moreover, medical records review revealed that R1 received services from a home health agency.

On September 14, 2019, Staff observed a change in R1’s condition, as R1 was unable to stand independently. Therefore, R1 was transported to the hospital for evaluation. On the same day, R1 returned to the facility with new medication orders to treat an acute medical condition. On September 15, 2019, R1 was transported back to the hospital, as a result of continuous weakness and an altered state of mind. While at the hospital additional testing was performed and was diagnosed with pneumonia.

Interviews with staff confirmed that they first observed the left heel wound on September 18, 2019, and as a result staff notified R1’s treating physician. On September 20, 2019, the treating physician examined R1, described the wound on the left heel as a blister, and provided wound care, as well as prescribed additional medical services by notifying home health. On September 25, 2019, a home health professional initiated services and conducted a full-body exam. The wound nurse described the wound located on the left heel as a blister and the injury on the right side of R1’s ear as a scab. According to those records, the next medical visit was scheduled for September 29, 2019.

On September 29, 2019, R1 returned to the hospital for the third time, due to increased weakness. Upon admission, R1 was re-examined and the assessment revealed a Stage III pressure injury located on the left heel and a Stage II pressure injury located on the right ear.

In addition to staff interviews, medical professionals were interviewed by the Department. Their interviews suggested that the injuries could have happened at the hospital and/or during transport. A review of medical records revealed no documentation of such injuries prior to the September 29, 2019 hospital visits. R1 was unable to be interviewed due to their altered cognitive state. Staff interviews denied that the injuries occurred while in their care. A review of home health agency records (date) showed that the agency provided left heel wound care, along with monitoring the decline of R1’s mental state from September 24, 2019 to October 09, 2019.

Based on the Department’s overall evidence, there is insufficient evidence to prove or disprove that the pressure injuries developed under the care of the licensed facility; therefore, the complaint investigation findings is found to be unsubstantiated. An exit interview was conducted with Administrator Sandy Krasovec and the Licensee’s Rights (LIC9058 01/16) along with a copy of this report was provided to the administrator via email. A reply email or return receipt from the administrator will confirm receipt of documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica Torres	TELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

LIC9099 (FAS) - (06/04)

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