374603509-9-16-2022-08-AS-IESA-CJRVG9-20220930162509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603509
Report Date: 09/16/2022
Date Signed: 09/16/2022 01:41:48 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
09/02/2020 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20200902111313

FACILITY NAME:	WESTMONT AT SAN MIGUEL RANCH		FACILITY NUMBER:	374603509
ADMINISTRATOR:	NEWTON, RANDAL		FACILITY TYPE:	740
ADDRESS:	2325 PROCTOR VALLEY RD		TELEPHONE:	(619) 271-4385
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91914
CAPACITY:	105	CENSUS: 82	DATE:	09/16/2022
		UNANNOUNCED	TIME BEGAN:	12:21 PM
MET WITH:	William Byrne, Executive Director (Interim)		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Questionable Death

INVESTIGATION FINDINGS:

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On 09/16/2022 at about 12:20 PM, Licensing Program Analyst (LPA) Daniel Pena, conducted an unannounced visit to the facility to conclude a complaint investigation. LPA was met at the entrance and after identifying himself and displaying his department identification, was allowed inside the facility. LPA met with Interim Executive Director, William Byrne to whom LPA discussed the elements of the complaint.

On 09/02/2020, it was alleged that neglect contributed to the death of Resident 1 (R1), who passed away at the hospital and under medical care on 07/18/2020. The Department’s investigation consisted of record reviews and interviews with staff, responsible persons and outside sources.

Facility records reflect that R1 was assessed and admitted into the facility in May 2020. Documentation showed that R1 was ambulatory and able to transfer independently to and from bed. R1’s primary diagnosis was major neurocognitive disorder and dementia. R1 required assistance with medication management, dressing and cash resource supervision.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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-20200902111313

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH	FACILITY NUMBER: 374603509
	VISIT DATE: 09/16/2022

NARRATIVE

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Per facility records, on 7/16/2020, at approximately 8:38 PM, staff noticed blood in R1’s urine. When asked, R1 denied pain or discomfort. Facility staff assessed R1 finding R1’s vitals normal. Staff notified R1’s primary care physician (PCP), requesting a urinalysis (UA). Staff made several attempts to collect urine samples (per PCP orders) but R1 was uncooperative. R1 was stable from 7/16/2020 to 07/17/2020 and therefore, not transferred to the hospital. R1 was placed on alert charting and monitoring during this time.

On 7/18/2020, at approximately 4:15 AM, R1 had an episode of loose bowel movement on their bedroom floor. R1 complained of lower abdomen pain. Facility staff activated emergency medical response via 911. R1 was transported to the hospital Emergency Room (ER).

Medical records showed that on 07/18/2020 at about 5:00 AM, R1 arrived at the hospital by ambulance. The primary medical complaint indicated rectal bleeding. During early rounds, hospital staff found R1 with red loose bowel movements and they activated medics. An IV was placed. At about 7:45 AM, staff checked R1 who appeared to be sleeping. Shortly later, staff went to check R1 as the monitor was disconnected. R1 was found lying on the floor unresponsive and no pulse.

Due to R1’s Do Not Resuscitate/Do Not Intubate (DNR/DNI) status, R1 passed away at the hospital under medical care. R1`s death certificate disclosed the immediate cause of death as Non-St Segment Elevational Myocardial Infarction; Acute Hypotension; Pneumonia and Probable Gastrointestinal Bleed Cause Unknown. Other significant conditions contributing to R1’s death but not resulting in the underlying cause given; Alzheimer’s dementia with behavioral disturbance, diabetes mellitus type 2; chronic kidney disease stage 2.

Interviews and record reviews did not reveal a lapse or delay in staff’s response to R1’s medical condition. Interviews with R1’s responsible persons (RP) stated that R1 was deteriorating quickly. RP said they were notified by staff that blood was found in R1’s waste. RP was informed that staff contacted R1’s physician about the blood and the fact that they were having difficulties obtaining urine samples. Interviews with outside sources, did not reveal evidence of neglect. When asked if staff could have done anything differently in their response to R1’s medical condition, outside sources said, “No.” Outside source interviews did not expose any concerns or complaints with staff response to R1’s medical condition.

Due to a lack of supporting evidence, the finding regarding the allegation that neglect resulted in the

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200902111313

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: WESTMONT AT SAN MIGUEL RANCH	FACILITY NUMBER: 374603509
	VISIT DATE: 09/16/2022

NARRATIVE

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questionable death of Resident 1 is Unsubstantiated. This finding means that although the allegation may have occurred or could be valid, there is not a preponderance of evidence to prove the alleged violation occurred.

An exit interview was conducted with Director Byrne and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) were provided and Director Byrne's signature on this form confirms receipt of these reports.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC9099 (FAS) - (06/04)

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