374604057-12-20-2022-08-AS-JRAE-CML3CP-20221229170817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604057
Report Date: 12/20/2022
Date Signed: 12/20/2022 10:06:37 AM

Unsubstantiated

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
04/16/2020 and conducted by Evaluator Iby Strong

COMPLAINT CONTROL NUMBER: 08-AS-20200416124948

FACILITY NAME:	ELMCROFT OF LA MESA		FACILITY NUMBER:	374604057
ADMINISTRATOR:	HEBNER, WES		FACILITY TYPE:	740
ADDRESS:	4960 MILLS STREET		TELEPHONE:	(619) 644-1100
CITY:	LA MESA	STATE: CA	ZIP CODE:	91941
CAPACITY:	56	CENSUS: 37	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Executive Director Jennie Ayersman		TIME COMPLETED:	09:35 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained multiple pressure injuries while in care
Staff left resident in soiled sheets for an extended period of time

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Jennie Ayersman, Operational Specialist Divinia Nunez was also present.

On April 16th, 2020, Community Care Licensing (CCL) received a complaint alleging resident sustained multiple pressure injuries while in care, and staff left resident in soiled sheets for an extended period of time.

During investigation, LPA Strong collected pertinent resident records, facility documentation and conducted multiple interviews. According to allegations, on or about April 2020, unidentified hospice residents sustained pressure injuries in the heel area, tail bone, and hip area while in care and that hospice residents were being left in soiled bedding.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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 2

Control Number 08-AS-20200416124948

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: ELMCROFT OF LA MESA	FACILITY NUMBER: 374604057
	VISIT DATE: 12/20/2022

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

According to records collected from facility, during April 2020, there were five residents receiving hospice services. Out of those five residents, only Resident 1 (R1) was receiving wound care from an outsourced hospice agency. According to R1’s Physician’s Report signed November 26^th, 2019, R1 was diagnosed with a Major Neurocognitive Disorder, bladder impairment, required continuous bed care, and had a history of skin condition or breakdown. According to hospice agency R1 notes, R1’s skin remained intact within limits of disease process from date of admission to hospice on July 25^th, 2019 until April 29^th, 2020. Interview with hospice agency nurse providing care to R1 during this time frame, revealed that nurse did not observe R1 being left in soiled bed or resident developing further wounds. There were no additional facility records found, during the time period in question, which revealed additional hospice residents having active pressure injuries.

Additionally, during investigation, LPA Strong interviewed multiple staff and outside sources. During interviews a responsible party for a hospice resident from April 2020, stated that Resident 2 (R2) was left in soiled incontinence pad for long periods of time. According to R2’s Physician Report dated November 12^th, 2019, R2 was diagnosed with a Major Neurocognitive Disorder, had bladder and bowel impairment and could communicate needs at times. During interview, responsible party could not provide a definite time frame for how long R2 had been left in soiled pad. Additional interviews with other outside sources revealed that there were no issues observed regarding facility staff leaving hospice residents in soiled bedding. Staff interviews revealed that current staff could not identify hospice residents from April 2020, being left in soiled bedding. Records reviewed revealed that facility does not have a system in place to document resident incontinence pad changes or changes in soiled bedding.

Based on LPA's interviews with staff, outside source interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are determined to be unsubstantiated. An exit interview was conducted with Executive Director Jennie Ayersman, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2