374604060-4-13-2022-08-AS-IESA-CDY82J-20220429220800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604060
Report Date: 04/12/2022
Date Signed: 04/13/2022 05:51:45 PM

Substantiated

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
01/19/2022 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20220119084723

FACILITY NAME:	GROSSMONT GARDENS SENIOR LIVING		FACILITY NUMBER:	374604060
ADMINISTRATOR:	KAITLIN RUDOLPH		FACILITY TYPE:	740
ADDRESS:	5480 MARENGO AVE		TELEPHONE:	(619) 463-0281
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	425	CENSUS: 179	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Associate Executive Director Lane Hermosillo		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Licensee did not meet COVID-19 infection control requirements for a resident in quarantine.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by and identified himself to receptionist Rosalinda Aquino. LPA then met with and discussed the purpose of the visit with Associate Executive Director Lane Hermosillo.

It was alleged that Licensee did not meet COVID-19 infection control requirements for Resident #1 (R1), who was under COVID-19 room quarantine during part of January 2022. Specifically, the complainant alleged: a) R1’s bedroom door was left continuously ajar when it should have been kept closed to prevent the spread of infectious droplets, and b) facility staff entered R1’s bedroom without using hand sanitizer, a protective gown, or eye protection. CCLD’s investigation consisted of touring the facility, observing direct care staff interacting with COVID-positive residents, and interviewing staff. The Department also reviewed photographic evidence, the facility’s LIC808 COVID-19 Mitigation Plan, a visit report from San Diego County Health and Human Services Agency’s Healthcare Associated Infection (HAI) team, and CCLD data about COVID-19 suspected and confirmed cases at the facility. [CONTINUED ON LIC 9099-C, 1 of 3]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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 5

Control Number 08-AS-20220119084723

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: GROSSMONT GARDENS SENIOR LIVING	FACILITY NUMBER: 374604060
	VISIT DATE: 04/12/2022

NARRATIVE

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[CONTINUED FROM LIC 9099]

During the timeframe of the complaint, R1’s primary physician (PCP) interpreted R1’s x-ray results as possibly showing “COVID-19 pneumonia,” but there was no formal diagnosis and R1 showed no outward symptoms. Licensee consulted with LPA and placed R1 into pre-emptive private room quarantine, pending further testing and communication with PCP. [This action was authorized by CDSS Provider Information Notice (PIN) 21-12-ASC and then-standing orders of San Diego County Health Officer Dr. Wilma Wooten.] R1 remained in quarantine status for approximately two weeks. (R1 was subsequently tested twice for COVID-19 and both results were negative.) Nonetheless, during said two-week period, licensee was required to carry out R1’s room quarantine in the manner specified in PIN 21-12-ASC. According to the PIN, R1 met category criteria for “Yellow-Person Under Investigation.” Staff entering R1’s quarantine bedroom were thus required to wear each of the following Personal Protective Equipment (PPE): An N-95 Respirator, a protective gown, eye protection, and gloves. (Licensee possessed enough of each of the above PPE articles throughout January 2022, as confirmed by LPA and HAI nurses during a January 3, 2022 site visit, and via several consultative phone calls between LPA and the administrator throughout the remainder of the month.) Staff were also required to perform hand hygiene before putting on gloves to care specifically for R1, and again after taking those same gloves off.

During interviews, facility leaders displayed consistent comprehension of PIN 21-12-ASC’s requirements. They corroborated that the facility’s protocol also included: a) having enhanced PPE in plastic drawers just outside each COVID-19 quarantine/isolation bedroom, b) staff having access to PPE reserves to replenish said drawers as needed, c) staff keeping the front doors of such bedrooms closed, except for moments of entry/exit, to better contain infectious airborne droplets, and d) staff performing hand hygiene upon putting on and removing their gloves, and discarding used gowns in a designated trash can inside the room. These points were also codified in the facility’s LIC808 COVID-19 Mitigation Plan. Ultimately, the Department found that Licensee’s expectations of its front line staff differed from their actual practices. LPA acquired two photographs; according to electronic timestamps, they were taken on the same day in January 2022, when R1 was still under quarantine status. The first photograph showed R1’s bedroom door wide open; R1’s walker is visible inside the room, from the hallway. In the second photograph, R1’s nameplate is visible next to the door, confirming that this was indeed R1’s bedroom. [CONTINUED ON LIC 9099-C, 2 of 3]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 08-AS-20220119084723

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: GROSSMONT GARDENS SENIOR LIVING	FACILITY NUMBER: 374604060
	VISIT DATE: 04/12/2022

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 3]

On January 27, 2022, LPA conducted an unannounced tour of the facility. [By this date, R1 had met criteria to be released from room quarantine, but Resident #2 (R2) and Resident #3 (R3) remained in active bedroom isolation status due to their recent COVID-positive test results.] LPA observed R2’s bedroom door was kept closed and immediately outside was a plastic drawer set containing N-95 respirators, trash bags, hand sanitizer, gloves, disinfecting wipes, and alcohol. Missing were protective gowns and face shields/eye protection. Staff #1 (S1) was the assigned caregiver for R2 on this date. S1 wore an N-95 respirator and correctly stated that R2 was on room isolation protocol. LPA said he would wait in the hallway, but asked S1 to check R2’s symptoms and body temperature. Upon seeing no gowns in front of R2’s room, S1 left for eight minutes to locate some. S1 then performed hand hygiene and was about to enter R2’s room wearing gown and gloves, but with no eye protection/face shield. When LPA asked about the latter, S1 said they were not aware eye protection was required, and they did not know where it was stored within the facility. (LPA subsequently provided S1 with a new face shield from his backpack). As S1 entered R2’s bedroom, they correctly closed the door behind them. However, after checking on R2, S1 came back out into the hallway with their gown still on, necessitating LPA to remind them to remove and discard it in the designated trash can inside the bedroom. S1 went back inside to remove it, then performed hand hygiene after exiting.

During the same visit, LPA observed R3’s bedroom door was kept closed and immediately outside was a plastic drawer set containing N-95 respirators, trash bags, hand sanitizer, gloves, and gowns. Missing were face shields/eye protection. Staff #2 (S2) was the assigned caregiver for R3 on this date. S2 wore an N-95 respirator and correctly stated that R3 was on room isolation protocol. LPA said he would wait in the hallway, but asked S2 to check R3’s symptoms and body temperature. S2 was about to enter R3’s room without performing hand hygiene or putting on gloves or gown. (They corrected this after LPA stopped them). However, S2 said they were not aware eye protection was required, and they did not know where it was stored within the facility. (LPA subsequently provided S2 with a new face shield from his backpack). As S2 entered R3’s bedroom, they did not close the door behind them. After checking on R3, they correctly removed and discarded their gown inside the room and performed hand hygiene on exit.

[CONTINUED ON LIC 9099-C, 3 of 3]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 08-AS-20220119084723

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: GROSSMONT GARDENS SENIOR LIVING	FACILITY NUMBER: 374604060
	VISIT DATE: 04/12/2022

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 2 of 3]

Based on photographs, staff interviews, records reviewed, and LPA’s observations, a preponderance of evidence exists to support the allegation that facility staff did not fully meet CDSS’ COVID-19 infection control requirements for a resident in quarantine. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Hermosillo, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20220119084723

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: GROSSMONT GARDENS SENIOR LIVING	FACILITY NUMBER: 374604060
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/12/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful…accommodations.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Administrator shall confer with HAI nurses and coordinate retraining of frontline employees. The training will cover a) PIN 21-12-ASC’s guidance on the correct way to set up and maintain a COVID-19 isolation or quarantine room, and b) hands-on practice with donning and doffing gowns, gloves, surgical masks, N-95 respirators, and face shields. Administrator shall submit the training-sign in sheet, plus photographic evidence of the hands-on component, to LPA by the POC due date.
	8 9 10 11 12 13 14	Based on photographic evidence, interviews, and LPA observations, licensee did not accord residents specific required safe and healthful accommodations. This posed a potential health risk to 179 of 179 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.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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