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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603431
Report Date: 12/15/2023
Date Signed: 12/15/2023 02:25:57 PM


Document Has Been Signed on 12/15/2023 02:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:ACTIVCARE AT ROLLING HILLS RANCHFACILITY NUMBER:
374603431
ADMINISTRATOR:BONGHABIH N. SHEYFACILITY TYPE:
740
ADDRESS:850 DUNCAN RANCH ROADTELEPHONE:
(619) 482-8000
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:60CENSUS: 42DATE:
12/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Program Director Karen Pultorak and Executive Director Bonghabih “BeeBee” Shey TIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Program Director Karen Pultorak. LPA also met with Executive Director Bonghabih “BeeBee” Shey, who arrived later during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/06/2023), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a facility tour and welfare check on R1 and other residents in care. LPA reviewed and collected copies of pertinent care, hospital, and personnel records. LPA also interviewed relevant staff and outside sources and observed the facility’s mechanical lift machines.

According to R1’s latest LIC602 Physician’s Report (dated 08/04/2023): R1 was diagnosed with “Advanced Dementia” and “Gait Disorder,” was wheelchair-bound, and required use of a “Hoyer Lift” machine to transfer from bed to wheelchair, and vice versa. The Needs and Services Plan which licensee authored on R1 reiterated that R1 was “non-weight-bearing” and “wheelchair bound.”

Due to their baseline memory loss, R1 could not recall the above incident. However, records and staff interviews showed: On the morning of 11/29/2023, Staff #1 (S1), without the assistance of a teammate, used a Hoyer Lift machine to try to transfer R1 from bed to wheelchair. The two legs of the Hoyer Lift machine were not spread and locked in the wide-open position (to maximize stability) while R1 was suspended in the air (via the associated sling). During a subsequent pivot maneuver, the machine tipped over and R1 landed on the floor of their bedroom. [CONTINUED ON LIC 809-C, 1 of 2]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ACTIVCARE AT ROLLING HILLS RANCH
FACILITY NUMBER: 374603431
VISIT DATE: 12/15/2023
NARRATIVE
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[CONTINUED FROM LIC 809] During the landing, R1’s right arm / shoulder was pinned between a chair and a small dresser, which were nearby. A facility nurse quickly determined R1’s had pain and limited range of motion and phoned 911. R1 was sent to a hospital emergency room where they were diagnosed with a fracture of their right humerus (a bone in the upper arm). R1 was discharged back to the facility later the same day, with a sling for their arm and as-needed pain medication.

Staff interviews unanimously showed: Even prior to this incident, licensee’s training expectations for its direct care staff included: a) use of the Hoyer Lift machine must be accompanied by assistance of at least two staff persons to ensure safety; and, b) the legs of the Hoyer Lift machine must be locked in the open-wide position prior to lifting a resident. Personnel and training records showed: Following the incident, Licensee performed written corrective action and coaching with S1 on 11/29/2023 and 12/06/2023. On 12/11/2023 and 12/13/2023, Licensee also retrained its larger direct care staff team on correct use of Mechanical Lifts; the training included a skills validation component.

Manager and staff interviews, corroborated by the facility’s work schedule, showed: The AM shift on 11/29/2023 (when the incident occurred) was fully staffed at the caregiver, med tech, and nurse positions (i.e., there was no shortage of teammates available to S1 to ask for help with the Hoyer Lift machine). Following the incident, licensee inspected the specific Hoyer Lift machine and sling used during the incident and found them free of defects – LPA observation of said machine and sling, during today’s visit, confirmed this. S1 admitted to CCLD that their performance with the Hoyer Lift machine on 11/29/2023 did not display the level of competence necessary to ensure R1’s safety.

Interviews of staff and outside sources showed: As R1 was being sent to the hospital on 11/29/2023, facility staff timely notified R1’s physician and responsible person (RP) of the incident via phone call, then sent a written LIC624 Incident Report to CCLD on 12/06/2023. However, the licensee did not send a copy of the LIC624 to R1’s responsible person, which was required to be done within seven days of incident occurrence.


[CONTINUED ON LIC 809-C, 2 of 2]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ACTIVCARE AT ROLLING HILLS RANCH
FACILITY NUMBER: 374603431
VISIT DATE: 12/15/2023
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

A preponderance of evidence exists to show that during the incident in question, licensee’s staff (S1) did not display competence necessary to meet a resident’s needs, which was material to R1 sustaining serious bodily injury. A preponderance of evidence exists to show that licensee did not fully meet reporting requirements.

Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). An immediate civil penalty of $500 was also assessed (refer to the LIC421-IM). Plans of Correction was jointly developed with the licensee.

LPA also provided Technical Assistance (TA) regarding another Hoyer Lift machine present at the facility, different than the one used by S1 during the above incident (refer to the LIC9102-TA).

An exit interview was conducted with Shey, to whom a copy of this report, the LIC 809-D, the LIC421-IM, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/15/2023 02:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: ACTIVCARE AT ROLLING HILLS RANCH
FACILITY NUMBER: 374603431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2023
Section Cited
CCR
87411(a)

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87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be…competent to provide the services necessary to meet resident needs.” This requirement was not met, as evidenced by:
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Personnel and training records showed: Following the incident, Licensee performed written corrective action and coaching with S1 on 11/29/2023 and 12/06/2023. On 12/11/2023 and 12/13/2023, Licensee also retrained its larger direct care staff team on correct use of Mechanical Lifts; the training included a skills-validation component. These actions resolve the deficiency.
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Based on interviews, the licensee did not ensure a facility personnel (S1) was competent to provide the services necessary to meet the needs of 1 of 42 residents (R1), which posed an immediate health and safety risk to persons in care.
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Type B
12/16/2023
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident."
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During today’s visit, Licensee E-mailed a copy of the written LIC624 Incident Report to R1’s responsible person. This action resolves the deficiency.
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This requirement was not met, as evidenced by: Based on records and interviews, 1 of 42 residents (R1) had an incident which threatened their welfare, safety, or health, and Licensee did not submit a written report of the incident to the person responsible for the resident within seven days of incident occurrence. This posed a potential personal rights risk to persons in care.
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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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4