374604081-1-6-2023-08-AS-SJAB-CMXSCS-20230110124558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604081
Report Date: 01/06/2023
Date Signed: 01/06/2023 02:11:09 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
12/17/2020 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20201217121625

FACILITY NAME:	NORTH LA COSTA ASSISTED LIVING, LLC		FACILITY NUMBER:	374604081
ADMINISTRATOR:	BOSKOSKI, DEJAN		FACILITY TYPE:	740
ADDRESS:	7623 PRIMAVERA WAY		TELEPHONE:	(760) 632-7290
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92009
CAPACITY:	6	CENSUS: 5	DATE:	01/06/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Dejan Boskoski, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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-Resident developed pressure injuries while in care
-Facility staff did not ensure that resident had an adequate intake of liquids
-Facility staff did not seek medical attention in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced facility visit to follow up on a complaint investigation regarding the above-mentioned allegations. LPA identified himself, explained the purpose of the visit and nature of the complaint to Administrator, Dejan Boskoski.

On 12/17/2020, the Department received this complaint which alleged, Resident 1 (See LIC811 Confidential Names to identify R1) developed pressure injuries while in care, facility staff did not ensure R1 had an adequate intake of liquids and did not seek medical attention for R1 in a timely manner. The Department’s investigation included, virtual and on site physical plant inspections, record reviews and interviews with residents, staff and outside sources.

A review of facility records included a self-reported unusual incident, involving R1. On 12/14/2020. R1 informed facility staff they were not feeling good and experiencing pain. Staff called R1’s hospice provider and reported the concern but was told R1 had an appointment with a nurse later in the week and would

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: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

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 3

Control Number 08-AS-20201217121625

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: NORTH LA COSTA ASSISTED LIVING, LLC	FACILITY NUMBER: 374604081
	VISIT DATE: 01/06/2023

NARRATIVE

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be seen then. Staff asked the hospice agency to send a nurse to immediately evaluate R1, but the agency said they could not. Facility staff then called R1’s conservator to advise them of the situation and informed them that that 911 would be called for R1. Facility staff called 911 and remained on the phone until paramedics arrived. R1 was admitted to the hospital and received treatment. R1 returned to the facility and still currently resides there.

During R1’s hospital admission, a health care professional observed R1 was in decline and non-verbal. The source indicated R1 was admitted with elevated sodium levels, wounds and dehydration. The source stated R1 was on hospice and receiving bathing services twice a week. The source said they spoke with the hospice provider about R1’s wounds but the agency said they were unaware of any skin conditions. The source expressed concerns for the care provided by the hospice agency, not R1’s licensed residential care facility.

Hospice record reviews revealed that R1 began receiving hospice services on 9/26/2020 with a terminal diagnosis of Senile Degeneration of Brain. At the time of hospice admission, R1 resided at another licensed care facility. R1’s hospice admission contract showed that a hospice aide was supposed to visit facility twice per week and as needed to assist R1 with personal care, home making and to promote comfort per nurse assignment. Additionally, hospice records showed the provider was to perform Peri-area skin maintenance which was to include cleanse with warm water and soap, pat dry and apply skin protectant daily and as needed for skin maintenance. The record did not show the presence of an existing skin condition or wound. R1 was admitted to North La Costa Assisted Living on 12/02/2020 and appraised by the administrator. R1's appraisal report showed no evidence of skin condition or dehydration. R1’s Physician Report showed they required assistance with all Activities of Daily Living (ADL) but the documentation did not show evidence of skin conditions or wounds.

R1’s conservator was interviewed and stated, North La Costa Assisted Living staff identified the change in R1's condition and took action to get R1 medical treatment. The conservator stated R1’s dehydration was identified at R1's previous facility and due to sepsis. R1’s conservator said, the hospice agency provided decent care, but they were not totally impressed with them. After R1 returned from the hospital, the facility administrator and R1's conservator met with the hospice agency. Following this meeting, hospice aides visited R1 three times a week until R1 was cleared from hospice in 2022. R1 still resides at North La Costa Assisted Living and is seen regularly by home health nurses and a physician.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20201217121625

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: NORTH LA COSTA ASSISTED LIVING, LLC	FACILITY NUMBER: 374604081
	VISIT DATE: 01/06/2023

NARRATIVE

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When asked, the conservator said North La Costa Assisted Living staff did a "fantastic" job providing care to R1. The conservator said it was facility staff who identified R1's medical issues and immediately sought medical treatment. The source also said the facility followed up with the hospice provider once R1 returned from the hospital.

The Department has investigated the allegations that R1 developed pressure injuries while in care, facility staff did not ensure R1 had an adequate intake of liquids and staff did not seek medical attention for R1 in a timely manner. Based upon the information obtained during this investigation; it is determined that although the incidents may have happened and are valid, there is not a preponderance of evidence to prove they occurred and are therefore UNSUBSTANTIATED.

An exit interview was conducted with Administrator Boskoski, to whom a copy of this report and the Licensee's Rights (LIC9058 01/16) were provided via hard copy.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC9099 (FAS) - (06/04)

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