374604103-10-5-2022-08-AS-IESA-CJZ46E-20221007184924

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604103
Report Date: 10/05/2022
Date Signed: 10/05/2022 04:24:03 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
10/15/2020 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20201015154555

FACILITY NAME:	SIENNA AT OTAY RANCH SENIOR LIVING		FACILITY NUMBER:	374604103
ADMINISTRATOR:	MENDEZ, RUBY GOMEZ		FACILITY TYPE:	740
ADDRESS:	1290 SANTA ROSA DR		TELEPHONE:	(619) 550-4521
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY:	0	CENSUS: 0	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Report Mailed to Licensee		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Licensee unlawfully retained a resident with a Prohibited Health Condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen completed an investigation regarding the above prior complaint allegation. Since the facility closed on 08-25-2021 due to change in ownership, the allegation finding was delivered to licensee via USPS certified mail.

It was alleged that Resident #1 (R1) had skin breakdown their bottom that was either a Stage 3 or Stage 4 pressure injury, and that instead of relocating R1 due to this prohibited health condition, licensee continued to care for them, unlawfully. (The complainant made clear they did not allege that licensee neglect occured, or that licensee caused said pressure injury. CCLD's investigation also did not show evidence of neglect.) CCLD’s investigation consisted of an unannounced facility tour/welfare check, interviews of relevant staff and residents, and review of pertinent facility, hospice, and government records.

[CONTINUED ON LIC 9099-C, 1 of 2]

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: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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 3

Control Number 08-AS-20201015154555

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: SIENNA AT OTAY RANCH SENIOR LIVING	FACILITY NUMBER: 374604103
	VISIT DATE: 10/05/2022

NARRATIVE

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[CONTINUED FROM LIC 9099]

Interviews and care records unanimously corroborated that R1 moved into the facility on 09-30-2020 with a terminal diagnosis/illness of “End Stage Alzheimer’s Disease,” for which R1 was under the concurrent care of a hospice agency. R1 also had end-stage chronic kidney disease, was “bedridden,” required “total care” including feeding and being on a pureed texture diet, and experienced decreased appetite/weight loss prior to arrival. During this time R1 lived at the facility, Licensee maintained its Hospice Care Waiver, approved by CCLD, in force. Electronic care notes showed that on R1’s move-in date, facility staff observed two small pre-existing pressure injuries on R1's bottom and notified R1’s hospice agency. The hospice agency began wound care services to R1 later that week, and continued it through the date of R1’s passing.

Licensee’ Service/Care Plan on R1 included checking their continence products about every 2 hours (changing and cleaning as needed), and rotating/repositioning them, when they were in bed, about every 2 hours to promote skin integrity. It also indicated wound care for “coccyx (stage 2)” was being provided by R1’s hospice skilled nurse. This wound care plan was also described in R1’s hospice agency plan of care (i.e. “…cleanse with [normal saline], apply MediHoney, cover with sacral gauze,…3X per week and [as needed] if dressing becomes soiled/dislodged…”) and reiterated in physician orders and visit notes written by hospice nurses. Interviews and care logs showed that R1’s skin care was a coordinated effort between facility and hospice staff, that facility staff received ongoing training from hospice staff, that R1’s Service Plan was consistently followed by both groups, and that they kept R1’s responsible party informed of changes in R1’s condition.

R1’s appetite declined to eating only a few bites daily and the skin on their bottom deteriorated, as did their overall health. On 10-21-2020, hospice staff wrote that R1’s coccyx pressure injury had progressed from Stage 2 to Stage 3. From 11-18-2020 through 11-23-2020, they increased wound care to R1’s bottom to daily frequency. Despite this, by 11-21-2020, R1 had developed new skin redness on their left hip, left foot, right elbow, and center of back. By 11-23-2020, hospice staff noted R1’s bottom progressed to Stage 4. On 11-25-2020, R1 passed away. According to their official death certificate, R1’s primary cause of death was Alzheimer’s Disease; there was no connection to pressure injuries or possible complications arising from such.

[CONTINUED ON LIC 9099-C, 2 of 2]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20201015154555

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: SIENNA AT OTAY RANCH SENIOR LIVING	FACILITY NUMBER: 374604103
	VISIT DATE: 10/05/2022

NARRATIVE

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[CONTINUED FROM LIC 9099-C, 1 of 2]

According to regulations, Stage 3 and 4 pressure injuries are generally “prohibited health conditions” within the Residential Care Facilities for the Elderly (RCFE) setting. However, a licensee may retain for a resident who has a “prohibited health condition,” provided: a) the licensee possesses an active CCLD-approved Hospice Care Waiver, b) the resident in question is receiving hospice services for a terminal illness, and c) the treatment of the prohibited health condition is addressed in the resident’s hospice care plan. In the case of R1: a) licensee maintained its CCLD-approved hospice waiver throughout the time R1 lived at the facility, b) a physician certified in writing that R1’s Alzheimer’s Disease prognosis was “six months or less,” and c) hospice’s wound care for R1 began before their prohibited health condition even developed and continued through C1’s date of death. The wound care was specifically described in R1’s hospice care plan.

Records and interviews provided additional context about R1's status as a hospice patient and the trajectory of their terminal illness. There does not exist a preponderance of evidence showing that licensee violated any regulation by retaining R1 at the facility even after the skin on R1’s bottom progressed to Stage 3 pressure injury, and then Stage 4. The allegation is therefore unsubstantiated. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were mailed to licensee via USPS certified mail.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

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