374603237-2-5-2021-08-AS-DPOL-BYGTJU-20210222134655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603237
Report Date: 02/05/2021
Date Signed: 02/05/2021 11:54:34 AM

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
05/14/2020 and conducted by Evaluator Jonathan C Pineda

COMPLAINT CONTROL NUMBER: 08-AS-20200514084345

FACILITY NAME:	ROXIES ELDERLY HOMES II		FACILITY NUMBER:	374603237
ADMINISTRATOR:	TERESITA ROXAS		FACILITY TYPE:	740
ADDRESS:	4560 VINYARD STREET		TELEPHONE:	(760) 637-2789
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS: 5	DATE:	02/05/2021
		UNANNOUNCED	TIME BEGAN:	11:04 AM
MET WITH:	Teresita Roxas, Administrator		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident’s pressure injury worsened while in care
Facility does not have a waiver to treat a resident
Facility did not seek timely medical attention for a resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jonathan Pineda conducted an unannounced complaint tele-visit to deliver findings on the above allegations. The visit was conducted via a tele-visit due to COVID-19. LPA identified himself to Teresita Roxas, Administrator and stated the purpose of the visit.

The Department's investigation consisted of record review, interviews with staff, outside sources, and observations.

It was alleged that resident’s pressure injury worsened while in care. Investigation revealed that Resident 1 (R1) (See Confidential Names List) was admitted to the facility on April 4, 2020 with a stage two pressure injury. Interview with two (2) out of two (2) staff revealed they were turning R1 as recommended and followed all instructions given by the Home Health Care Provider. Interview with an outside source revealed during the month of May 2020, R1 was receiving three visits per week from a nurse for ostomy, Foley, and wound care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Jonathan C Pineda
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021

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 2

Control Number 08-AS-20200514084345

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: ROXIES ELDERLY HOMES II	FACILITY NUMBER: 374603237
	VISIT DATE: 02/05/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

In addition, R1 was receiving two visits per week from a physical therapist. Observations and record review revealed there was no evidence to indicate the facility failed to follow R1’s care plan.

It was alleged that facility does not have a waiver to treat a resident. Record review revealed R1 was admitted to the facility on April 4, 2020 with a stage two (2) pressure injury. R1 was visited by the Home Health Care Provider on May 11, 2020 who reported R1’s pressure injury needed to be evaluated. Record review revealed that R1’s pressure injury was not staged as a three (3) until May 12, 2020. On May 13, 2020, the Home Health Care Provider determined R1 could not continue to reside at the facility and needed to go to the hospital. Licensee Teresita Roxas was notified, and R1 was transferred to the hospital via ambulance.

It was alleged that facility did not seek timely medical attention for a resident. Interview with an outside source revealed there was not a delay in getting R1 medical attention once it was determined they needed to be hospitalized. Once it was determined that R1 needed to be hospitalized, they drove to the facility to help facilitate R1’s transfer. When they arrived, S1 had already transported R1 to the hospital. Observations revealed there is no evidence to indicate the facility failed to provide timely medical attention once it was determined that R1 needed hospitalization.

Based on observations, review of records, interviews, and outside sources, and observation, it is determined that the allegations are UNSUBSTANTIATED. There is not a preponderance of the evidence to prove the allegations occurred.

An exit interview was conducted with Teresita Roxas, Administrator. A copy of this report LIC 9099 along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Teresita via email. An electronic email read receipt confirms the documents were received.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Jonathan C Pineda
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2