<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603815
Report Date: 10/30/2023
Date Signed: 10/30/2023 05:10:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
04/28/2020 and conducted by Evaluator Becky Kennedy
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20200428113435
FACILITY NAME:SOLARIS 36FACILITY NUMBER:
374603815
ADMINISTRATOR:ARCA, LUCIAFACILITY TYPE:
740
ADDRESS:14536 GARDEN RDTELEPHONE:
(844) 320-1497
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 5DATE:
10/30/2023
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:TIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect contributed to resident developing pressure injury(ies).0
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA was met by Vely Vidal, Caregiver and was granted entry into the facility. LPM met with Anafe Rivera, Site Manager to discuss the purpose of the visit.
Investigation consisted of interviews with residents, staff, outside sources, record review, and a tour of the facility. It was alleged that neglect resulted in serious bodily injury of Resident #1 (R1). A Confidential Names form was provided to Ms. Rivera. Investigation revealed R1 was admitted to the facility in January 2020. Record review and interviews revealed R1 was receiving hospice services from admission until April 2, 2020, at which point hey discharged and were followed by a home health agency from April 3, 2020, through their move out date on April 27, 2020. Review of R1’s medical assessment, dated January 11, 2020, revealed R1 had a history of skin breakdown. R1 was incontinent of bowel and bladder and considered non-ambulatory. Review of R1’s resident appraisal and hospice documents upon admission did not note that R1 had skin problems. Hospice records from January 15, 2020, documented R1 had some dermatitis on their inner buttocks.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Icela Estrada
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
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 6
Control Number 08-AS-20200428113435
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SOLARIS 36
FACILITY NUMBER: 374603815
VISIT DATE: 10/30/2023
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
All areas of skin on R1 were closed. Interviews with facility caregivers and managers unanimously corroborated that while there was some rash R1’s bottom at time of move in, there were no actual open areas of skin.

Staff and outside interviews, and R1’s LIC602 Physician’s Report, corroborate that R1 was incontinent and wheelchair dependent. According to R1’s Hospice Plan of Care, R1 needed to be turned and repositioned in bed every 2 hours, and hospice nurses educated facility staff on the importance of preventing skin breakdown as opposed to wound treatment. Records and interviews revealed R1 was discharged from Hospice on April 2, 2020, and began services with a Home Health Agency (HHA) on April 3, 2020. Record review from the HHA, noted that between April 4, 2020, and April 9, 2020, four different HH staff documented that they provided facility staff education on how to maintain R1’s skin integrity. On April 9, 2020, HHA staff instructed facility staff to implement a turning schedule which restricted R1’s time in one position for 2 hours or less as R1 was restricted to bed. They also instructed staff to float R1’s heels off their bed surface at all times. Interviews with direct care staff revealed staff knew R1 needed to be rotated/repositioned when in bed, but no staff provided that they knew R1’s heels needed to be floated above the bed surface. Although R1’s HHA instructed R1 needed to be repositioned/rotated in bed every 2 hours or less, interviews of R1’s actual caregivers showed while R1 was in bed staff stated they turned R1 every 2-3 hours, and twice during the night. None of the staff stated they floated R1’s heels above the bed surface. Review of facility records revealed the licensee was unable to produce a Needs and Services Plan / Care Plan for R1.

SUPERVISORS NAME: Icela Estrada
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20200428113435
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SOLARIS 36
FACILITY NUMBER: 374603815
VISIT DATE: 10/30/2023
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
Review of Hospice records revealed that from January 13, 2020, through April 2, 2020, the rash on R1’s bottom was effectively managed with creams. R1’s skin remained closed and there were no pressure injuries to R1’s bottom during this period. There was no documented problem with skin on R1’s heels or back during this time either. Review of HHA records corroborate that when hospice ended and HHA took over, R1 did not have pressure injuries and their feet were assessed and appeared normal. HHA noted a mass on R1’s sacrum, but it was intact and not red. Interviews with staff corroborated that R1 moved into the facility with a pre-existing raised bump on their sacrum, but it was closed and normal-skin tone at that time. Staff interviews revealed that on or about April 1, 2020, staff observed that R1 developed a 1-inch by 3-inch pressure injury to R1’s right buttock which involved the top layer of skin. Staff did not describe this wound as deep. The mass on R1’s sacrum had turned bluish or purplish, had opened up, was weeping yellowish discharge, and had foul odor. Facility care staff notified their supervisor who corroborated that the wound on R1’s sacrum had opened up by April 1, 2020, and that over time it got worse and developed foul odor and discharge. Staff stated the wound was reported to HHA staff, R1’s physician, and R1’s responsible party.

Review of R1’s HHA records revealed that on April 24, 2020, R1’s feet were still intact, but there was now a stage 2 pressure injury to R1’s coccyx. By April 26, 2020, a HHA physician upgraded the pressure injury to a stage 3 pressure injury, and on April 27, 2020, medical professionals documented wounds to R1’s entire buttock and lower back with wound infection and very foul-smelling drainage. The wounds on R1’s buttock was covered with necrotic tissue. According to medical professionals, on April 27, 2020, R1 met all criteria for severe sepsis and required immediate intervention. R1 was observed with shallow breathing, rectal bleeding, and was very lethargic and difficult to arouse. R1 was transported to a hospital and was admitted for inpatient treatment.

SUPERVISORS NAME: Icela Estrada
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20200428113435
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SOLARIS 36
FACILITY NUMBER: 374603815
VISIT DATE: 10/30/2023
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
Review of hospital records revealed R1 was diagnosed with multiple stage 3 pressure injuries on their back, heels, and coccyx, and a stage 4 pressure injury of the sacrum that required surgery. Medical professionals noted that there was extremely foul-smelling pus coming from the pressure injuries on R1’s sacrum and buttocks, and that these latter ulcers had likely been there for some time. The stage 4 pressure injury over the sacrum was 5 x 8 cm with an abscess cavity covered by necrotic tissue; a stage 3 pressure injury of the right buttock measuring 3 X 5 cm with necrotic tan-like skin; a stage 2 pressure injury of the left buttock measuring 2 x 3 cm; and unstageable pressure injuries of the bilateral heels measuring 3 x 3 cm. Hospital records also noted that there was infected skin and subcutaneous tissue, fascia, and muscle all the way down to the sacral bone. During the surgery, medical professionals found R1’s sacral bone had “bony prominences” that contributed to the formation of pressure ulcers. Although R1 had bony prominences that contributed to the formation of the pressure injuries, interviews with staff revealed that staff did not comply with R1’s care plan and turning and repositioning schedule and did not float R1’s heels.

R1 passed away on July 3, 2020. According to R1’s death certificate, R1 passed away due to Acute Respiratory Failure, and Primary Central Nervous System Lymphoma. There were no other significant conditions contributing to R1’s death.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is deemed substantiated. A civil penalty in the amount of $500 is being assessed per Health and Safety Code 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1. Determination of Civil Penalties under Health and Safety Code Section 1569.49 are pending and under review by the Program Administrator of the Community Care Licensing Division.

SUPERVISORS NAME: Icela Estrada
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20200428113435
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SOLARIS 36
FACILITY NUMBER: 374603815
VISIT DATE: 10/30/2023
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
On today’s date, the Department is issuing a $500.00 civil penalty under HSC 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1.

This deficiency is being cited per California code of Regulations, Title 22, on the attached LIC 9099D.

An exit interview was conducted with XXXXX and a copy of this report, LIC 421IM – Civil Penalty Assessment Form, and Licensee/Appeal Rights (LIC 9058 01/16), were provided to them at the conclusion of the visit.

SUPERVISORS NAME: Icela Estrada
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20200428113435
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SOLARIS 36
FACILITY NUMBER: 374603815
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2023
Section Cited
HSC
1569.39(d)
1
2
3
4
5
6
7
ASSISTANCE WITH ACCESSING HOME HEALTH OR HOSPICE SERVICES; RECEIPT OF MEDICAL SERVICES - Failure to meet or arrange to meet the needs of those residents who require health-related services as specified in the resident’s written record of care...is a licensing violation and subject to civil penalty pursuant to Section 1569.49.
1
2
3
4
5
6
7
Facility will conduct an in-service training for all staff that provide care to residents on wound prevention including turning timing, documentaion and staff communication regarding care provision. Attendance and training content will be sent to licensing by POC date.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure the written record of care identified by the home health agency for one 1 of 6 residents was not being followed. This posed an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Icela Estrada
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6