374603371-6-9-2022-08-AS-IESA-CG2UPG-20220705154529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603371
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:27:15 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
03/09/2020 and conducted by Evaluator Vicky Williamson

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20200309124140

FACILITY NAME:	MERRILL GARDENS AT OCEANSIDE		FACILITY NUMBER:	374603371
ADMINISTRATOR:	PEREZ, MARIANO		FACILITY TYPE:	740
ADDRESS:	3500 LAKE BLVD		TELEPHONE:	(760) 414-9411
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92056
CAPACITY:	0	CENSUS: 0	DATE:	06/09/2022
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Report Mailed to former licensee via USPS Certified Mail		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff failed to monitor resident's food intake resulting in death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vicky Williamson sent this report to the former licensee at their last known mailing address via USPS certified mail and via email to deliver the investigation findings for the above allegation. The facility ceased operations on or about September 24, 2021.

The Department’s investigation consisted of interviews with staff, outside sources, and review of records, to include medical records. It was alleged that staff failed to monitor resident’s food intake resulting in death of Resident #1 (R1). Facility was provided with Form LIC 811 - Confidential Names Form, to identify R1. Investigation revealed that R1 was admitted to the facility on April 5, 2019. Review of medical records revealed that on April 4, 2019, R1 was placed on a puree diet, and on June 13, 2019, R1’s diet was changed from pureed foods to a mechanical soft/chopped food. R1 had dementia and prior to admission to the facility, R1 was diagnosed with Gerd and Esophageal.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky Williamson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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-20200309124140

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: MERRILL GARDENS AT OCEANSIDE	FACILITY NUMBER: 374603371
	VISIT DATE: 06/09/2022

NARRATIVE

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On August 3, 2019, sometime after 8:00 p.m. staff #1 (S1) indicated that she provided R1 and Resident #2 (R2) a snack consisting of a roast beef sandwich. R1 and R2’s sandwich had already been cut into half by kitchen staff. S1 took the sandwich and made an additionally cut, cutting it in half before giving it to R1. S1 described the sandwich as being the size of the palm of her hand. S1 states that she observed R1 take a bite of the sandwich, then replace the remainder of the sandwich on her plate. R1 opened her mouth to show S1 that she swallowed the bite that she took. S1 states that she left R1 and R2 for approximately 1 ½ minutes to go across the hall to get laundry from the dryer. When S1 returned, she observed R1 was laying on the floor in the hallway. R1’s skin was discolored, her eyes were open, and she was not breathing. S1 states that she felt a lite pulse. S1 rolled R1 to her side and did a finger sweep in her mouth. S1 removed a small piece of bread from the roof of R1’s mouth and initiated CPR. The Oceanside Fire Department paramedics arrived at the facility at 8:34 p.m. and took over care of R1. A review of the 911 fire/Paramedic response report, and an interview with an outside source confirms that after removing a meat substance from R1’s airways, described to be the size of a golf ball, and attempting oxygenation; R1’s pulse was never regained. R1 was pronounced deceased at the facility at 8:46 p.m.

Facility staff acknowledge that they were aware that R1 was on a mechanical soft/chopped food diet. Staff interviews revealed that the kitchen staff are notified of resident’s dietary restrictions and how the food should be prepared. Caregivers are responsible for ensuring that the food consist of the proper diet or prepared, monitoring residents with swallowing issues to ensure they swallow their food and not choke. Interviews with facility staff indicated that R1 takes food from other resident’s plates, and on occasions place too much food in her mouth causing her to spit or throw up her food.

The incident was self reported to Community Care Licensing as an unknown death, with no mention of choking. A review of the Medical Examiner’s Report and Death Certificate indicated the cause of death as Asphyxia due to Occlusion of airway by food bolus.

The Department has investigated the above-mentioned allegation that staff failed to monitor resident’s food intake resulting in R1 aspirating on food bolus. Based upon review of facility, medical records, information from outside sources and interviews conducted during the investigation, the preponderance of the evidence standard has been met. Therefore, the allegation is deemed substantiated.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky Williamson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200309124140

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: MERRILL GARDENS AT OCEANSIDE	FACILITY NUMBER: 374603371
	VISIT DATE: 06/09/2022

NARRATIVE

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At this time, per Health and Safety Code Section 1569.49 (e), a civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.

The deficiency is noted on the attached 9099-D and is cited in accordance with the California Code of Regulations, Title 22. A copy of this report along with Licensee/Appeal Rights (LIC 9058) was mailed via USPS Certified Mail to the former licensee’s mailing address on file.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Vicky Williamson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20200309124140

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: MERRILL GARDENS AT OCEANSIDE	FACILITY NUMBER: 374603371
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/09/2022 Section Cited CCR 87555(b)(7)	1 2 3 4 5 6 7	87555(b)(7) General Food Service Requirements. Modified diets prescribed by a resident's physician as a medical necessity shall be provided. The requirement was not met as evidenced by: Based on interviews, review of facility and medical records, staff did not monitor	1 2 3 4 5 6 7	Deficiency cleared on this date as evidenced by facility closure, September 24, 2021.
	8 9 10 11 12 13 14	R1's food intake or follow R1's special diet as noted on the physician's report; causing R1 to aspirate on food bolus resulting in the death of R1. This posed an immediate health risk to R1.	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: Vicky Williamson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC9099 (FAS) - (06/04)

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