374602620-7-14-2022-08-AS-IESA-CGTTSM-20220730145922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602620
Report Date: 07/14/2022
Date Signed: 07/14/2022 10:38:03 PM

Unsubstantiated

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
08/11/2020 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20200811115142

FACILITY NAME:	PINE TREE HOME, LLC		FACILITY NUMBER:	374602620
ADMINISTRATOR:	SIMSUANGCO, LEONARDO		FACILITY TYPE:	740
ADDRESS:	4603 RAINIER AVENUE		TELEPHONE:	(619) 280-3338
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92120
CAPACITY:	6	CENSUS: 6	DATE:	07/14/2022
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Caregiver Gloria Pascua		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Neglect to resident resulting in a pressure injury.
Failure to seek medical attention.
Facility retained a resident with a prohibited health condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above listed complaint allegations. LPA Correia met with Caregiver Gloria Pascua to whom was explained the purpose for the visit.

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

It was alleged that Resident (R1) sustained a pressure injury due to staff neglect. An interview with facility staff and a resident record review revealed R1 was admitted to the facility on July 23, 2019. At the time of admission, R1 was diagnosed with Mild Intellectual Disabilities (MID), Dementia, Hyperlipemia, Hypertension, Cerebral Palsy, was legally blind, and had cellulitis on their right lower limb. R1 required full assistance with ADL’s.

Unsubstantiated

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: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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-20200811115142

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: PINE TREE HOME, LLC	FACILITY NUMBER: 374602620
	VISIT DATE: 07/14/2022

NARRATIVE

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An interview conducted on September 29, 2020 with facility Staff1 (S1) revealed R1 received home health services three (3) days a week. S1 also revealed on August 3, 2020 they observed a small blister on R1’s lower back. S1 notified the facility Administrator (S2) on that same day. Interviews with S1 and S2 revealed on August 4, 2020 R1’s primary doctor and home health agency were notified about the pressure injury. An outside source record review corroborated that on August 4, 2020 facility staff notified R1’s home health agency and R1 was seen by a nurse on that same day. Interviews with facility staff and an outside source record review also revealed on, August 4, 2020, R1’s attending nurse instructed facility staff how to care for R1’s wound. An interview with S1 revealed on August 7, 2020 R1’s injury appeared to have worsened and S1 facilitated having R1 transported to the emergency room (ER) of a hospital. A review of medical records corroborates R1 was transported to the ER on August 7, 2020.

It was also alleged facility staff failed to seek medical attention for R1, and the facility retained R1 with a restricted health condition. An interview with S2 revealed toward the third week of July 2020 R1 began to have trouble swallowing, and R1 started to refuse to eat their pureed food. R1 also developed a pressure injury while at the facility. Staff and outside source interviews, as well as resident and medical record reviews revealed at the time of the alleged violations R1 was under the care of a home health service and was being seen by medical professionals three times a week. Both the home health agency and R1’s primary doctor were informed and aware of R1’s prognosis.

Due to lack of corroborating evidence, the finding regarding the above allegations were established to be unsubstantiated. This finding means there is not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted with Caregiver Pascua and a copy of this report along with Licensee Rights (LIC 9058 01/16) was provided to Caregiver Pascua. Signature on the for confirms receipt the reports were received.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC9099 (FAS) - (06/04)

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