374602528-5-27-2022-08-AS-IESA-CEYVKV-20220601163058

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602528
Report Date: 05/27/2022
Date Signed: 05/27/2022 04:30:46 PM

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
02/24/2021 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20210224155641

FACILITY NAME:	ANSHIN HOME CARE		FACILITY NUMBER:	374602528
ADMINISTRATOR:	TODA, KUNINOBU		FACILITY TYPE:	740
ADDRESS:	9412 HILMER DRIVE		TELEPHONE:	(619) 867-2341
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	6	CENSUS: 2	DATE:	05/27/2022
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Licensee Toda Kuninobu and Administrator Maria Osorio		TIME COMPLETED:	01:29 PM

ALLEGATION(S):

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Neglect resulting in resident developing pressure injuries.

INVESTIGATION FINDINGS:

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Regional Manager (RM) Icela Estrada and Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegation. RM Estrada and LPA Correia met with Licensee Kuninobu and Administrator Osorio, identified themselves, and explained the purpose of the visit.

The Department’s investigation consisted of facility staff and outside source interviews, and a facility tour. The investigation also included facility, medical, and resident record reviews.

It was alleged that Resident1 (R1) (See Confidential Names List LIC 811) sustained four (4) pressure injuries while residing at the facility. Prior to admission, R1 suffered a stroke causing paralysis to the left side of their body. R1 was wheelchair bound, diagnosed with Mild Intellectual Disability (MID) and was a one-person assist. R1 was admitted to the facility on January 20, 2020.

Substantiated

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: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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-20210224155641

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: ANSHIN HOME CARE	FACILITY NUMBER: 374602528
	VISIT DATE: 05/27/2022

NARRATIVE

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Prior to admission, R1’s Physician’s Report signed on December 29, 2019 revealed R1 had skin tears on arms, legs, left buttock, and right heel. R1’s Physician’s Report dated January 17, 2020 did not include any documentation regarding R1 having wounds or skin tears. Outside source documentation revealed that on March 10, 2021, Licensee reported that R1 had no open wounds or pressure injuries and they had not experienced any issues with R1 regarding weight loss. A review of R1’s facility file revealed no documentation of changes in conditions or re-appraisals.

On March 9, 2021, an interview with Licensee and S1 (S1) revealed in February of 2021 (day unknown), S1 was bathing R1 and observed a wound in R1’s pelvic area and two more near their left knee. The Licensee notified R1’s Responsible Party (RP) about the three wounds and told the RP that S1 was treating the wounds by cleaning and re-dressing them. As time went on S1 felt unable to successfully treat the wounds and notified Outside Source 1 (OS1) to seek medical attention. An interview with OS1 corroborated being notified about the wounds but was given the impression the wounds were small and not serious. At the time of the allegation, OS1 was unable to visit the facility to observe R1 due to the COVID-19 pandemic. OS1 feared putting R1 at risk for contracting COVID-19 by removing R1 from the facility to get assessed at a hospital. OS1 requested that facility staff have R1’s medical provider come to the facility to have R1’s wounds assessed. However, R1’s medical provider did not offer home visits or provide mobile medical services at that time due to COVID-19. During the interview with the Licensee and S1, they were asked why they did not call 911 to have R1 sent to the hospital for an evaluation. The respondents were unable to answer the question other than that the family had expressed concern regarding transporting R1 during the pandemic.

A medical record review revealed that on February 17, 2021, R1’s medical provider received notification regarding R1’s condition. On February 23, 2021, OS1 transported R1 to their primary care physician where they were diagnosed with four unstageable wounds. R1 was also observed to have lost twenty-four pounds (106lbs to 82lbs) over the past year. Due to the pressure injuries and significant weight loss, R1 was immediately sent and admitted to the hospital. An interview with the attending medical provider revealed the pressure injuries were a result from sitting still for long periods of time and poor nutrition. In addition, the pressure injuries can take weeks to develop into unstageable pressure injuries. At that time the attending medical provider also submitted an APS report regarding R1’s health conditions.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210224155641

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: ANSHIN HOME CARE	FACILITY NUMBER: 374602528
	VISIT DATE: 05/27/2022

NARRATIVE

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R1 was released from the hospital on February 28, 2021 to another licensed facility and passed away four days later. An additional review of medical records revealed R1 had two unstageable pressure injuries and bilateral hip pressure injuries.

Based on LPA’s investigation, the above allegation was determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. At this time, per Health and Safety Code Section 1569.49, a civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.

RM Estrada conducted an exit interview with Administrator Osorio. At the time of the conclusion of the visit was given a copy of the Complaint Investigation Report and the Licensee /Appeal Rights (LIC9058 01-2016), 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: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20210224155641

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: ANSHIN HOME CARE	FACILITY NUMBER: 374602528
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/20/2022 Section Cited CCR 87464(F)(1)	1 2 3 4 5 6 7	Basuc Services (F) Basic services 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).	1 2 3 4 5 6 7	Licensee Toda and Administrator Osorio will seek CCL approved vendor training regarding the care and supervision on residents experiencing serious, including but not limited to, restricted and/or prohibited health condintions. Toda and Osorio will provide CCL proof of training by POC due date.
	8 9 10 11 12 13 14	Based on staff and outside source interviews, and medical and facility record review, the Licensee did not provide care and supervision to 1 out of 3 residents (Resident #1) which posed an immediate health 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: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC9099 (FAS) - (06/04)

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