374604062-10-27-2022-08-AS-IESA-CKRA4P-20221031235353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604062
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:58:23 PM

Unsubstantiated

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
02/11/2021 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20210211105731

FACILITY NAME:	ELMCROFT OF POINT LOMA		FACILITY NUMBER:	374604062
ADMINISTRATOR:	SHEARER, KELLIE		FACILITY TYPE:	740
ADDRESS:	3423 CHANNEL WAY		TELEPHONE:	(619) 224-7300
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92110
CAPACITY:	60	CENSUS: 45	DATE:	10/27/2022
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Kellie Shearer, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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-Staff neglect resulted in a resident sustaining multiple fractures
-Staff did not seek medical attention to a resident in care

INVESTIGATION FINDINGS:

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On 10/27/2022, at approximately 11:55 AM, Licensing Program Analyst (LPA) Daniel Pena, conducted an unannounced visit to the facility to conclude a complaint investigation. LPA was met at the entrance by Administrator, Kellie Shearer. After identifying himself and displaying his department identification, LPA was allowed inside the facility. LPA met with Ms. Shearer to whom the elements of the complaint were discussed.

On 2/11/2021, the Department initiated an investigation into two complaint allegations; (1) staff neglect of a resident, resulted in multiple fractures, and (2) staff did not seek medical attention for a resident in care.

The Department’s investigation consisted of facility and outside source record reviews, and interviews with facility staff, responsible parties, and outside sources. In order to protect the privacy of the focus resident, they are referred to as Resident 1 (R1) throughout this report. Records reflect that R1 was admitted into the licensed care facility on 11/27/2019 and resided there until their passing on 02/01/2021.

Unsubstantiated

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: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210211105731

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: ELMCROFT OF POINT LOMA	FACILITY NUMBER: 374604062
	VISIT DATE: 10/27/2022

NARRATIVE

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Per R1’s 11/23/2019 Physician Report, Dementia and Hypertension were the primary diagnosis. R1 was nonambulatory and required assistance with all Activities of Daily Living (ADL). R1’s overall health status was fair. A review of R1’s facility records illustrate that R1 was a well documented fall risk. Records also noted that R1 was receiving hospice care.

Medical and facility records noted three documented falls while R1 resided at Elmcroft of Point Loma. On 03/26/20, records showed that R1 experienced an unwitnessed fall at the facility which resulted in hospitalization. Hospital records indicated the following injuries: closed fracture of multiple ribs of right side, closed fracture of right upper extremity, other intraarticular fracture of lower end of right radius, unspecified fracture of lower end of right ulna, and unspecified displaced fracture of surgical neck of right humerus. Interviews and records showed that R1’s arm was stabilized with a splint and they returned to the community the next day.

Additionally, on 05/17/20, R1 endured a second fall and was sent to the hospital with no visible injuries and on 12/28/20, R1 had a third fall which resulted in transport to the hospital; no injuries reported. It should be noted that these three incidents were reported to CCLD and R1’s primary care provider and responsible party were notified.

It was also alleged that the facility did not seek medical attention for a resident (R1) in care. Facility and outside source records confirmed that R1 was sent to the hospital after each fall. In two of the three fall incidents, R1 did not present visible injuries or complain of pain. Nonetheless, R1 was sent to the hospital out of precaution. R1’s responsible party and primary care physician were notified after each fall.
R1’s medical records indicated the presence of demineralized bones (osteoporosis) or bone loss. R1 was documented as at risk for bone fractures even with everyday activities or minor accidents or falls. R1’s hospice provider developed a care plan which included fall risk mitigation strategies.

The hospice provider’s care plan included the issuance of a lowered bed; at least three inches from the floor. Hospice also provided R1 with a fall mat, high back wheelchair, one-hour safety checks, rotating every two hours and body pillows. The hospice provider reassessed and updated R1’s care plan on a regular basis. It is also documented that Elmcroft of Point Loma staff followed R1’s hospice care plan.

Based on the information gathered during the investigation, there is insufficient evidence to support the

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210211105731

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: ELMCROFT OF POINT LOMA	FACILITY NUMBER: 374604062
	VISIT DATE: 10/27/2022

NARRATIVE

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allegations that staff neglect, resulted in a resident sustaining multiple fractures and the facility did not seek medical attention in a timely manner. Therefore, the allegations are Unsubstantiated. Although the allegations associated with this complaint may have occurred or could be valid, there is not a preponderance of evidence to prove they occurred.

An exit interview was conducted with Administrator Shearer and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) were provided and Ms. Shearer’s signature on this form confirms receipt of these reports.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

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