374603625-3-1-2024-08-AS-SJAB-D3PTKM-20240325144810

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603625
Report Date: 03/01/2024
Date Signed: 03/01/2024 04:27:07 PM

Substantiated

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
02/21/2024 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20240221105822

FACILITY NAME:	STELLAR CARE		FACILITY NUMBER:	374603625
ADMINISTRATOR:	LINDA CHO		FACILITY TYPE:	740
ADDRESS:	4518 54TH STREET		TELEPHONE:	(619) 287-2920
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY:	120	CENSUS: 80	DATE:	03/01/2024
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Carrie Lopez, Community Relations Director		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff neglect resulted in wounds to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Pena initiated an investigation regarding the above-mentioned complaint. LPA introduced and identified himself and was allowed into the facility. LPA met with Carrie Lopez, Community Relations Director and discussed with her the elements of the complaint.

On 02/21/2024, Community Care Licensing Division (CCLD) received a complaint alleging staff neglect resulted in resident’s wound. An outside source reported that upon arrival to a local hospital, Resident 1 (R1) was observed to have two lesions/wounds. The wounds were observed on the resident’s right shoulder and right hip. The outside source reported concerns that the wounds were infected.

The Department’s investigation included interviews with staff, outside sources, review of records, and a visit to the facility. The Department was unable to interview R1. Facility records revealed that on 02/16/2024, R1 was found by staff laying on the floor of their room. Staff responded to assist and observed bleeding to the resident’s head. Emergency Medical Services (EMS-911) was called and picked up the resident for transport to a local hospital.

Substantiated

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: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

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-20240221105822

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: STELLAR CARE	FACILITY NUMBER: 374603625
	VISIT DATE: 03/01/2024

NARRATIVE

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The resident was evaluated in the Emergency Department and later admitted for further evaluation. Records reflect that hospital staff placed a staple on a laceration on the back of R1’s head. Records also reflect that R1 was admitted for treatment of an open area on the right shoulder and right hip.

A review of R1’s facility communication report indicates that on 02/07/2024, R1 presented to facility nursing with redness to the groin area. On 02/14/2024, records reflect a facility caregiver observed “redness to right hip and shoulder. Notified MT. MT checked vitals. Vitals normal – redness on body.” R1’s records noted that on 02/15/2024, R1 refused shower.

R1 was admitted to the facility on 10/26/2023. Per R1’s LIC602A Physician’s Report, dated 10/10/2023, R1’s primary diagnosis was Dementia, HTN, CKD, and Diabetes. R1’s secondary diagnosis was senile debility and a high risk for falls. R1’s physical health indicated they did not require assistance other than a regular low sugar diet. R1’s mental condition showed inappropriate and aggressive behavior, suicidal, at risk if allowed direct access to personal grooming and unable to leave the facility unassisted. R1’s records noted they were unable to bathe them self and needed supervision. R1’s records noted they were non-ambulatory based upon their mental condition.

Interviews with facility managers and supervisors revealed that R1 was very independent and at times refused bathing assistance. Management and supervisory staff acknowledged that R1’s plan of care included bathing assistance. Management interviews stated that when care staff provide bathing assistance, they are able to evaluate residents for skin breakdown or wounds. Interviews revealed that it was common knowledge R1 regularly refused bathing assistance. Management and supervisory staff did not arrange for R1 to be reevaluated so their plan of care could be updated. Management acknowledged that if staff followed R1’s plan of care, pertaining to bathing assistance, they could have discovered R1’s skin condition sooner. It was also noted by supervisory interviews that there was a delay by care staff in notifying supervision of R1’s wounds.

LPA obtained R1’s hospital records which noted that the admitting diagnosis were shoulder abscess, hip abscess, and cellulitis. An interview with an outside source indicates R1 remained at the hospital for treatment and was transferred to a rehabilitation facility on 2/23/24. The source told LPA that R1 is currently receiving treatment for Methicillin-resistant Staphylococcus aureus (MRSA) and will likely return to the facility after they recover.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240221105822

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: STELLAR CARE	FACILITY NUMBER: 374603625
	VISIT DATE: 03/01/2024

NARRATIVE

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The Department has investigated the above-mentioned allegation and has found that based upon evidence gathered during record review and interviews, there is sufficient evidence to corroborate the allegation. The Preponderance of Evidence standard was met. Therefore, the allegation is deemed substantiated. A deficiency is cited in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D.

An exit interview was conducted with Ms. Lopez and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) was provided. Ms. Lopez’ signature below confirms receipt of the documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20240221105822

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: STELLAR CARE	FACILITY NUMBER: 374603625
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/01/2024 Section Cited HSC 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. The requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will arrange vendorized training on Title 22, Section 87411 Personnel Requirements – General. Licensee agreed to provide proof of training to LPA by POC due date.
	8 9 10 11 12 13 14	Based upon interviews and record reviews, the licensee did not have sufficient numbers of competent personnel …to provide the services necessary to meet the needs of 1 of 80 persons in care which posed a potential risk to the health and safety of persons in care.	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: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

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