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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601936
Report Date: 01/20/2023
Date Signed: 01/20/2023 11:46:58 AM

Substantiated


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
08/04/2021 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20210804110059
FACILITY NAME:VMB ULTIMATE CAREFACILITY NUMBER:
374601936
ADMINISTRATOR:VIRGIL P. BUCATCATFACILITY TYPE:
740
ADDRESS:344 E 27TH STTELEPHONE:
(619) 434-4565
CITY:NATIONAL CITYSTATE: CAZIP CODE:
91950
CAPACITY:6CENSUS: 4DATE:
01/20/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:House Manager, Milagros BucatcatTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Resident eloped from facility resulting in serious injury
Facility did not follow reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Marisela Garcia-Centeno conducted an unannounced complaint visit to deliver findings on the above-mentioned allegations. LPA was met by House Manager, Milagros Bucatcat and was granted entry into the facility. Administrator, Virgil Bubcat joined the meeting via telephone as well as Acting Administrator, Martcela Marcelo and LPA shared the investigative findings. The Department’s investigation consisted of record reviews, including medical and outside source records and interviews with staff and outside sources. On 07/23/21, it was alleged that a resident eloped from the facility which resulted in serious bodily injuries that required hospitalization. It was also alleged the elopement incident was not reported by the licensee to the Department as required.

Resident #1 (R1) was admitted to the facility on May 15, 2019. R1 had a primary diagnosis of a Major Neurocognitive Disorder (severe dementia) with agitation and mood swings. R1 also was diagnosed with and under treatment for hypertension and type-2 diabetes. A physician’s report dated 4/29/21 stated R1 was often confused and disoriented and medically evaluated as unable to leave the facility unassisted. Review of the resident’s pre-appraisal form dated 4/29/21 stated R1 was ambulatory but had an unsteady gait and could not stand for long without assistance. R1 had a known history of wandering behaviors and required close staff supervision and monitoring. (Continue at LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
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-20210804110059
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: VMB ULTIMATE CARE
FACILITY NUMBER: 374601936
VISIT DATE: 01/20/2023
NARRATIVE
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(Continue from LIC9099)

Interviews and facility records revealed that on the afternoon of 07/23/21 R1 and a direct caregiver Staff #1 (S1) were outside smoking cigarettes on the facility front porch. S1 acknowledged during interview statements that they had been advised of R1’s prior elopements and knew R1 was not be left unsupervised. S1 admitted they left the resident alone for 10-15 minutes and went inside to use the bathroom. R1 was alone in an unsecured area of the facility that led directly out to the street. When S1 returned to the porch fifteen minutes later, at approximately 1:00 pm, R1 had left the facility unattended and was not in sight. S1 stated they advised the licensee, Staff #2 (S2) who was present at the facility and searched the immediate vicinity on foot but could not find the resident. When S1’s care shift ended at 6:00 pm in the evening, R1 had still not returned.

After the elopement occurred, S2 drove around local streets looking for R1 but acknowledged that they did not call 911 to report the elderly resident as missing. During interview statements, S2 claimed that they attempted to call a non-emergency police number and later went to the local police station that evening but the station was closed. S2 did not leave a voice message or other form of communication to advise law enforcement of the elopement. The next day, 7/24/21, at approximately 8:00 am, the licensee notified R1’s responsible party and other family members of the elopement. A family member then immediately reported R1 as at-risk missing person to local police and advised them R1 had been missing for nearly 24 hours.

At approximately 5:45 pm on the evening of 7/24/21, community members found R1 lying injured in a drainage ditch. The open ditch was located down a 20-foot sloped embankment in an empty construction lot several blocks away from the facility. A review of medical and outside source records confirmed that R1 was assessed with serious injuries including a badly fractured ankle, severe dehydration, and a black eye. R1 also had multiple bruises, abrasions and skin tears on their upper and lower extremities from falling into the ditch and a stage 2 pressure injury on their hip. The acute pressure injury was diagnosed as caused by R1 lying immobile for a prolonged period in one position. Medical records noted the resident was “covered in ants and dried feces” and was observed as confused, disoriented and expressing acute pain due to their injuries. R1 required immediate surgery for the ankle fracture and was hospitalized for five days, then discharged to a post-acute care skilled nursing facility.

(continue at LIC9099C)
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20210804110059
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: VMB ULTIMATE CARE
FACILITY NUMBER: 374601936
VISIT DATE: 01/20/2023
NARRATIVE
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(Continue from LIC9099)

During investigative interview statements, both S1 and S2 admitted that they knew this resident had a history of previous elopements: R1 had previously gone missing twice from their facility, most recently on 9/7/20 and was brought back by police each time, after neighbors observed the resident wandering away and called local law enforcement. Outside source records revealed that during a subsequent interview, the licensee stated they “did not think it was necessary to call 911” and decided to “wait and see” if the resident would return on their own. Licensee and staff statements also confirmed that they knew the resident had a medical diagnosis of severe cognitive impairment and required close supervision to prevent elopement risk. Based on multiple staff and outside source interviews and review of documentation including medical records, the allegations are substantiated.

This Department has investigated the allegations noted above. The Department has found that based upon records review and interviews gathered during the investigation, the preponderance of the evidence standard has been met. Therefore, these allegations are deemed substantiated. An immediate civil penalty in the amount of $500 is being assessed today and per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20210804110059
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: VMB ULTIMATE CARE
FACILITY NUMBER: 374601936
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2023
Section Cited
CCR
87464(f)(1)
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87464(f)(1) - Elopement resulting in serious bodily injury. Basic Sercices shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). "Care and supervision" means the facility assumes responsibility for, or provides ...., ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by:
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Licensee agreed to conduct training by an outside source on elopements/absent without leave (AWOL), supervision for residents in care. This training will be scheduled by 2/3/2023 and trainings will be completed by POC date of 2/21/2023.
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Interviews and record reviews showing staff left R1 unassisted on 7/23/21, resulting in elopement with serious bodily injury and hospitalization. This posed an immediate safety risk to one of six residents in care. Immediate CP of $500 assessed today
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Type B
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Section Cited
CCR
87211(a)(D)
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87211(a)(D) Reporting Requirements - Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met, as evidenced by:
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Licensee agreed to conduct training by an outside source on reporting requirements. This training will be scheduled by 2/3/2023 and trainings will be completed by POC date of 2/21/2023.
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Interviews and records review showing licensee did not report the elopement of R1 to local licensing as required. This posed an potential safety risk to one of six residents in care.
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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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4