374604063-2-14-2023-08-AS-IESA-CPH8WV-20230228215322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604063
Report Date: 02/14/2023
Date Signed: 02/14/2023 02:51:21 PM

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
12/02/2021 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20211202153136

FACILITY NAME:	MESAVIEW SENIOR ASSISTED LIVING		FACILITY NUMBER:	374604063
ADMINISTRATOR:	GENOVEVA GUERRERO		FACILITY TYPE:	740
ADDRESS:	7971 CULOWEE STREET		TELEPHONE:	(619) 466-0253
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	30	CENSUS: 30	DATE:	02/14/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator Genoveva Guerrero		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff neglect contributed to resident's death.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself, and discussed the purpose of the visit with Administrator Genoveva Guerrero.

It was alleged Resident #1 (R1) had an unwitnessed fall at the facility, for which staff reported R1 had no injury, but then R1 was hospitalized a few days later for a “traumatic subdural hematoma” which resulted in their death. CCLD’s investigation involved multiple unannounced facility tours/welfare checks and interviews of relevant staff and outside sources. The Department also reviewed the facility’s care/administrative documents on R1 and pertinent medical records from the hospital, a managed health group, a hemodialysis center, and other sources.

[CONTINUED ON LIC 9099-C, 1 of 4]

Unsubstantiated

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: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

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 5

Control Number 08-AS-20211202153136

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: MESAVIEW SENIOR ASSISTED LIVING	FACILITY NUMBER: 374604063
	VISIT DATE: 02/14/2023

NARRATIVE

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[CONTINUED FROM LIC 9099]

According to R1’s Admissions Agreement contract, Face Sheet, and other administrative records, R1 moved into Mesaview Senior Assisted Living (“Mesaview”) in late October 2021 as their own responsible party. R1 was concurrently a patient of a third-party managed health group (HG), where R1’s primary physician (P1) worked. Per R1’s LIC624 Physician’s Report, their end-stage renal disease primary diagnosis required them to attend offsite hemodialysis on “Tuesdays, Thursdays, and Saturdays.” P1 wrote R1 was “non-ambulatory,” used a wheelchair, and required assistance with mobility, toileting, and other personal care due to their right foot being partially amputated. R1 also had anemia, diabetes, a pacemaker, cataracts, mild hearing loss, and was alert and oriented but sometimes confused. R1’s LIC603 Pre-Placement Appraisal showed they were “non-ambulatory,” “feeble/slow,” used a wheelchair, and needed help with mobility, transferring, and toileting. Licensee’s Care Plans and Reappraisals on R1 echoed the above points and described R1 as “mildly confused,” “slightly forgetful,” and “can stand [and bear weight,] but not for long.” R1’s facility medication list, corroborated by HG and hospital records, showed R1 was taking two blood-thinner medications during timeframe of the alleged incident.

CCLD reviewed two pertinent LIC624 Incident Reports which licensee submitted before the current complaint was received. According to licensee’s first LIC624: on 11-26-2021 around 3:00 PM, Mesaview direct-care Staff #1 (S1) received a phone call from R1’s offsite dialysis center (DC); DC staff reported R1 was found on the floor of the center’s restroom. (This LIC624 did not indicate if R1 had injuries but said Mesaview staff contacted R1’s HG physician). According to licensee’s second LIC624: on 11-29-2021 around 4:00 AM, Mesaview direct-care Staff #2 (S2) called 911 because they observed R1 “having difficulty communicating and drooling.”

According to the dialysis center’s date and timestamped electronic notes, R1’s underwent a hemodialysis session on Saturday 11-27-2021 (and not Friday 11-26-2021, as was stated in licensee’s LIC624s and LIC624A). Per the center’s 11-27-2021 notes: a DC registered nurse (P2) wrote that R1 “was seen on the bathroom floor [with] the wheelchair on [their] back.” P2 and coworkers helped R1 get back into their wheelchair to finish using the restroom. R1 complained of “pain in both knees,” for which a “PRN [as-needed medication] for pain [was] given.” R1 had “no swelling or bruises noted.” [CONTINUED ON LIC 9099-C, 2 of 4]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 08-AS-20211202153136

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: MESAVIEW SENIOR ASSISTED LIVING	FACILITY NUMBER: 374604063
	VISIT DATE: 02/14/2023

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 4] P2 wrote that R1 “cannot recall what happened [inside the restroom],” but was “without nausea or vomiting or headache.” When CCLD interviewed P2 about the incident: they said prior to the start of their hemodialysis session, R1 was dropped off in the DC lobby. R1 took themselves to the restroom without asking anyone for help. Another patient alerted DC staff that R1 was on the floor of the restroom. P2 found R1 on their back, face up, with their left arm against the wall. P2 performed a head-to-toe assessment but found no bruising, swelling, bulging, or discoloration on R1’s head and body. When P2 asked R1 if they hit their head, R1 said no. R1’s only complaint was that their knees hurt, so P2 gave them Tylenol. R1 went on to complete their full 11-27-2021 hemodialysis session without visible complications. P2 said they notified Mesaview staff of the incident, but not the HG staff.

In their interviews, Mesaview staff could not remember names or exact dates, but said R1 acted differently after the hemodialysis session in question: S1 observed no visible injury on R1, but recalled R1 was tired, not eating, less responsive, and had impaired speech. S1 said they received a phone call from DC staff saying R1 went to the restroom by themselves and was found on the floor. S1 said they phoned HG staff to report R1’s symptoms and the fall at the DC. Mesaview direct-care Staff #3 (S3) observed no visible injury on R1, but said R1 was weak, not hungry, not speaking well, and not able to sit upright in a chair. S3 said it was HG staff who called them (and not the other way around) to report that R1 fell offsite. Mesaview direct-care Staff #4 (S4) observed no visible injury on R1, but said R1 was weak with poor appetite, which S4 reported to R1’s HG via phone “a couple of times” along with R1’s vital signs. S4 did not know about R1’s fall at the DC, but still asked R1 if they had fallen, to which R1 said no. S4 said HG staff told them R1’s symptoms were side effects of dialysis, and reassured S4 that R1 had a scheduled doctor’s appointment soon. S4 said HG staff told them to keep observing R1 and measuring their blood sugar. According to S2, during their overnight shift (which goes from late 11-28-2021 to early 11-29-2021), R1 initially slept without incident. During their 4:00 AM check, S2 found R1 on their bedroom floor, face up, with their body pointing towards the doorway. S2 observed no visible head injury or bleeding, but called 911 because R1 was drooling, drowsy, and unable to speak.

[CONTINUED ON LIC 9099-C, 3 of 4]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 08-AS-20211202153136

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: MESAVIEW SENIOR ASSISTED LIVING	FACILITY NUMBER: 374604063
	VISIT DATE: 02/14/2023

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 2 of 4]

According to the HG’s date and timestamped electronic progress notes: On 11-27-2021 around 4:26 PM, an HG registered nurse (P3) working on behalf of R1’s physician wrote that they spoke via phone with S3. P3 wrote R1 was “found on bathroom floor” with “no visible injuries,” but did not specify if the bathroom was located at Mesaview or at an alternate location. P3 wrote they instructed S3 to call back if R1 develops “pain or altered mental status.” On 11-28-2021 around 5:30 PM, P3 wrote they received a phone call from S4, who provided R1’s vital signs and said R1 was dizzy, weak, had not eaten lunch, and had around 8 episodes of diarrhea. P3 wrote they instructed S4 to give R1 fluids and that R1 had an appointment with their physician the next morning at 11:00 AM. In both above progress notes, P3 wrote “ER [Emergency Room] precautions [were] discussed” with S3 and S4, respectively. However, P3 did not write that a medical emergency already existed, or that they instructed facility staff to call 911 or to hold/pause R1’s blood thinner medications.

By the date of CCLD’s interview, P3 had left HG employment and no longer had access to their progress notes. However, P3 remembered R1 lived at Mesaview and was ordinarily “pretty independent in terms of thinking.” P3 confirmed being phoned by Mesaview staff about R1 falling and experiencing symptoms, but P3 could not remember where the fall occurred, what R1’s symptoms were, or how the HG responded. P3 confirmed they worked under the direction of R1’s physician (P1) and their duties included reporting patient information to P1 and relaying P1’s orders to others. In their own interview, P1 told CCLD their memory of R1 was not good enough to allow them to independently comment on events pertaining to R1. P1 deferred fully to the HG’s progress notes, which they said did not contain mention of R1’s fall at the dialysis center. R1’s HG social worker (P4) confirmed receiving CCLD’s multiple interview requests, but they did not respond to them. Per interview of HG senior manager (P5), who studied the HG’s progress notes on R1 and supervised P1, P3 and P4 during the timeframe of the complaint allegation: they were under the impression R1 fell inside a bathroom located at Mesaview. P5 confirmed HG staff did not instruct Mesaview staff to call 911 or to pause/hold R1’s blood thinner medications in response to R1’s reported fall or subsequent symptoms. P5 corroborated that during early morning of 11-29-2021, Mesaview staff independently (i.e., without further consulting the HG) called 911 to have R1 taken to a nearby ER for treatment.

[CONTINUED ON LIC 9099-C, 4 of 4]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20211202153136

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: MESAVIEW SENIOR ASSISTED LIVING	FACILITY NUMBER: 374604063
	VISIT DATE: 02/14/2023

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 3 of 4]

According to ambulance records: paramedics responded to a 911 call originating from Mesaview around 4:00 AM on 11-29-2021. They wrote R1 had since been moved to a wheelchair but had a “left lean in [their] sitting position” and “an obvious left sided facial droop.” When paramedics asked about pain, R1 had “slurred speech” but pointed to their own neck. R1 had “no outward signs of trauma” to their head, neck, or other body parts. According to hospital emergency room records: R1 was “on blood thinners” and diagnosed with “severe intracranial head bleed after a fall.” R1 had a “large right-sided subdural hematoma” and was given platelets “X2.” R1’s head was scanned before the transfusion, and again a few hours later; the second CT scan showed “the bleed was much larger” and “non-survivable.” R1 had “no acute cervical spine injury detected.” R1 soon became unresponsive, and physicians determined any “operation would be futile.” R1 underwent compassionate extubating and died on 12-02-2021. According to R1’s official/county death certificate, their immediate cause of death was, “Blunt Force Injury of the Head.”

According to R1’s LIC624A Death Report, which licensee submitted to CCLD before the current complaint was received: R1 fell on 11-26-2021 “while [they] were out [of the facility] with [the HG].” By the next day, R1 “was more unsteady than usual,” which S1 “reported to [the HG].” Then on 11-29-2021, R1 was found “found unresponsive, drooling and not able to communicate, and on the floor by [their] bed and door way” and was taken to the hospital, where they died on 12-02-2021. In their interview, the Mesaview manager who authored the LIC624A said their staff timely reported R1’s symptoms to the HG, but it was not immediately apparent to facility staff that R1’s symptoms were related to a head injury.

Based on interviews and records, a preponderance of evidence does not exist to show that licensee was culpable for R1’s fall at the dialysis center or for the subdural hematoma that took R1’s life. A preponderance of evidence does not exist to show that facility staff neglected to observe and report changes in R1’s physical condition to R1’s medical provider, or that they neglected to follow medical instructions leading up to R1’s hospitalization, or that they neglected to arrange emergency medical care for R1. The allegation is therefore unsubstantiated.

An exit interview was conducted with Guerrero, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

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