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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604057
Report Date: 08/24/2021
Date Signed: 08/25/2021 04:43:03 PM

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:ELMCROFT OF LA MESAFACILITY NUMBER:
374604057
ADMINISTRATOR:HEBNER, WESFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:56CENSUS: 26DATE:
08/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:31 PM
MET WITH:Executive Director, Wes HebnerTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management visit. LPA identified herself and discussed the purpose of the visit with Executive Director, Wes Hebner.

During today’s visit, LPA toured the facility and briefly observed residents. The reason for the visit is to issue deficiencies that were identified during a complaint investigation. Resident #1 (R1) was neglected, resulting in a pressure injury. R1 sustained a Stage II pressure injury that progressed to Unstageable. The Mayo Clinic defines pressure injuries can be classified into four (4) stages of increasing depth and severity, known as Stages one (1) thru four (4). However, they also have additional stages that exist known as unstageable injuries. Unstageable injuries are described as covered by dead tissue or eschar that obscures the ulcer base. The facility was using an outside nursing agency due to staff shortage caused by the Pandemic. A review of the facility’s records reflected the pressure injury on the left hip was observed by the facility nurse on 04/28/20 as a Stage II pressure injury. On 05/01/20, the facility staff documented in the resident notes that R1’s pressure injury was now unstageable on R1’s left hip area. Once the wound became unstageable, it is considered a prohibited health condition. The facility retained R1 with the prohibited health condition and did not request an exception. In addition, when R1 had a change in condition, due to the prohibited health condition, the facility did not conduct a reappraisal. Facility staff contacted R1’s physician to inquire about a plan of care for R1. However, the physician’s staff advised the facility to follow their protocol for wound care. The facility did not have a wound care protocol to follow or supporting documentation from a physician. Therefore, no physician’s orders or plan of care was in place to provide appropriate care to R1. In addition, staff interviews revealed there were no official medical orders, and the facility did not have the proper equipment for wound care. The outside nursing agency confirmed the nurses from the nursing agency were not wound care nurses. The facility didn’t ensure care is performed by or under the supervision of an appropriately skilled professional as outlined in Title 22 Regulations. Continued on LIC 9099C.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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: ELMCROFT OF LA MESA
FACILITY NUMBER: 374604057
VISIT DATE: 08/24/2021
NARRATIVE
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Based on interviews conducted and records reviewed, the facility failed to conduct a reappraisal and request an exception once R1 was identified with a prohibited health condition. In addition, the facility failed to obtain supporting documentation from R1’s physician to provide wound care and did not ensure an appropriate skilled professional with wound care experience provided the care to R1. The preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8, is being cited on the attached LIC 9099D. [See LIC 811 Confidential Names List to identify Resident #1].
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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: ELMCROFT OF LA MESA
FACILITY NUMBER: 374604057
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2021
Section Cited

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Documentation and Support. Each facility shall document in writing the findings...assessment which was necessary in accordance...If supporting documentation from a physician is required...required in Section 87458, Medical Assessment. This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee did not obtain supporting documentation for 1 [R1] out of 26 residents from a physician. This posed an immediate health risk to resident in care.
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Type A
08/25/2021
Section Cited

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Healing Wounds. Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: When care is performed by or under the supervision of an appropriately skilled professional. This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee did not request an exception for a prohibited health condition for 1 [R1] out of 26 residents. This posed an immediate health risk to resident 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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
Page: 3 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: ELMCROFT OF LA MESA
FACILITY NUMBER: 374604057
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2021
Section Cited

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Reappraisals. The pre-admission appraisal shall be updated...appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.
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This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not conduct a reappraisal for 1 [R1] out of 26 residents, once a change in condition was observed. This posed a potential health risk to resident in care.
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Type B
09/14/2021
Section Cited

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Exceptions for Health Conditions. As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
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This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not request an exception for a prohibited health condition regarding stage wounds for 1 [R1] out of 26 residents. This posed a potential health risk to resident 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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4