374602598-4-18-2021-08-AS-IESA-C2KW48-20210430165708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602598
Report Date: 03/31/2021
Date Signed: 04/18/2021 10:47:11 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
01/06/2020 and conducted by Evaluator Debbie Correia

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20200106144633

FACILITY NAME:	GOLDEN SUNSET RESIDENTIAL II		FACILITY NUMBER:	374602598
ADMINISTRATOR:	MIGUEL A MALONE		FACILITY TYPE:	740
ADDRESS:	7029 HILLSBORO STREET		TELEPHONE:	(619) 758-8493
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92120
CAPACITY:	6	CENSUS: 5	DATE:	03/31/2021
		UNANNOUNCED	TIME BEGAN:	06:30 PM
MET WITH:	Licensee, Miguel Malone		TIME COMPLETED:	08:15 PM

ALLEGATION(S):

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Licensee neglect resulted in serious bodily injury to a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted a visit via FaceTime to deliver findings due to COVID-19 regarding the above-mentioned allegation. LPA identified herself, and stated the purpose of the virtual visit.

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

An interview with the Licensee revealed Resident #1 (R1) [see LIC 811 Confidential Names List for identification of resident] was residing in a skilled nursing facility (SNF), from sustaining a hip fracture after fall at home, from November 2018 to February 2019. Upon release from the SNF, R1 was admitted to the facility. The Licensee indicated using R1’s discharge plan and medication schedule prepared on February 1, 2019, by the SNF as R1’s pre-placement appraisal for facility admission. A review of the discharge plan revealed it only provided instructions on proper care for the healing hip fracture and a pressure injury and did not meet the Title 22 requirements for a pre-appraisal.

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: 03/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/31/2021

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-20200106144633

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: GOLDEN SUNSET RESIDENTIAL II	FACILITY NUMBER: 374602598
	VISIT DATE: 03/31/2021

NARRATIVE

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A review of the discharge plan revealed it only provided instructions on proper care for the healing hip fracture and a pressure injury and did not meet the Title 22 requirements for a pre-appraisal. A review of facility records revealed a pre-appraisal was not conducted upon admission but was six (6) months after admission on August 29, 2019. The appraisal included minimal information, but did indicate the need for special observation due to forgetfulness, confusion and wandering. On August 29, 2019 there was also a doctor’s order for bed rails to reduce risk of falls.

The investigation revealed that while at the facility, R1 experienced multiple unwitnessed falls from their wheelchair, including a fall on August 21, 2019 that resulted in a hospital stay, and another fall on September 7, 2019 resulting in a hip fracture requiring surgery. An interview with facility staff (S1) reported that the fall on September 7, 2019 R1 was left unattended in the living room. S1 deemed R1 as a fall risk due to having knowledge of their fall history prior residing at the facility, and due to the subsequent falls at the facility to include the fall on November 29, 2019 in question. An interview with the Licensee revealed a different point of view of R1, although the Licensee had knowledge of their previous fall history and was present during each fall that occurred at the facility. Licensee stated never feeling that R1 was a fall risk due to being wheelchair bound. Evidence shows that the Licensee did not conduct an initial pre-appraisal at admission or re-appraisal after each fall to include obtaining an updated Physician’s Report. Resident records did not include a fall prevention plan as well.

Interview with S1 further revealed that R1 was able to unlock their wheelchair and had attempted several times to leave the facility by trying to push themselves through a facility door. The Licensee stated R1 tried to elope from the facility approximately 60% of the time. Outside source interview revealed R1’s elopement attempts were never reported to R1’s Power of Attorney (POA). The third fall happened on November 29, 2019 resulting in a fractured neck (C2 Vertebra) and 7-inch gash on their head requiring stitches. These injuries were a result of another attempt to elope from the facility by forcing through a door, and upon attempting, they fell out of their wheelchair and onto the cement walkway. Staff were alerted by the facility alarm and found R1 lying on the floor bleeding profusely from the head. Staff called 911 and R1 was transferred to the hospital and admitted to the Intensive Care Unit (ICU). Staff interviews revealed the Licensee and a caregiver were assisting another resident at the time of R1’s attempt to elope, leaving R1 unsupervised.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 03/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/31/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200106144633

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: GOLDEN SUNSET RESIDENTIAL II	FACILITY NUMBER: 374602598
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/31/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/10/2021 Section Cited CCR 87463(a)(3)	1 2 3 4 5 6 7	The pre-admission appraisal shall be updated, in writing...to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in physical, medical, mental, and social condition..not be limited to change in the health...specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to seek training on providing care and supervision to the elderly residing in his Residential Care Facilities for the Elderly (RCFE), through an approved vendor continuing education course.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on evidence from interviews, facility and medical records revealed that the Licensee did not conduct reappraisals when changes in R1’s condition occurred to ensure the health and safety of R1. This posed an immediate health and safety risk to one of six residents in care.	8 9 10 11 12 13 14	Licensee agreed to submit the following documents to CCLD by the POC date: certificate of completion for the Administrator by a vendor for training ; ensure pre-appraisal are completed at admission; daily observation logs. A civil penalty assessment is pending review by Program Administration.
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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: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 03/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/31/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200106144633

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: GOLDEN SUNSET RESIDENTIAL II	FACILITY NUMBER: 374602598
	VISIT DATE: 03/31/2021

NARRATIVE

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Based on interviews and a facility record and medical record reviews the above allegation is 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.

An exit interview was conducted with Licensee Malone via telephone and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) was provided to Licensee Malone via email. An electronic email read receipt confirms the documents were received.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 03/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/31/2021

LIC9099 (FAS) - (06/04)

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