374604115-1-12-2021-08-AS-IESA-BZGS6L-20210326133606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604115
Report Date: 01/12/2021
Date Signed: 01/12/2021 01:29:50 PM

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
10/16/2019 and conducted by Evaluator Jonathan C Pineda

COMPLAINT CONTROL NUMBER: 08-AS-20191016111516

FACILITY NAME:	COUNTRY ROSE ESTATE MEMORY CARE		FACILITY NUMBER:	374604115
ADMINISTRATOR:	PARAISO, CATHERINE T		FACILITY TYPE:	740
ADDRESS:	1255 ADVENTURE LN		TELEPHONE:	(760) 738-9391
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY:	15	CENSUS: 9	DATE:	01/12/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Val Paraiso		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Licensee did not provide food as ordered by physician which resulted in death
Licensee did not seek timely medical attention

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jonathan Pineda conducted an unannounced complaint tele-visit to deliver findings on the above allegations. The visit was conducted via Facetime due to COVID-19. LPA identified himself to Val Paraiso and stated the purpose of the visit.

The Department's investigation consisted of a tour of the facility, observations, interviews with staff, resident, outside sources, and a review of resident’s records and medical records.

It was alleged that facility did not provide food as indicated by physician to meet resident’s needs which resulted in death. Per hospice records, Resident 1 (R1, see List of Confidential Names), was placed on hospice with a terminal illness related to Alzheimer’s disease. Investigation revealed that on October 4, 2019, Resident 1 was discovered by caregivers to be aspirating food (breathing foreign objects into the airways, when one swallows) and hospice was immediately notified.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Jonathan C Pineda	TELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021

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-20191016111516

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: COUNTRY ROSE ESTATE MEMORY CARE	FACILITY NUMBER: 374604115
	VISIT DATE: 01/12/2021

NARRATIVE

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On October 5, 2019, R1 was placed on a nectar thick and pureed diet by the hospice speech pathologist following the aspiration. Staff immediately implemented R1’s diet. Investigation revealed R1 was having difficulty breathing beginning on October 8, 2019 around 11:00 PM. On October 9, 2019, hospice arrived around 12:15 AM to provide comfort measures. Hospice followed up at 7:00 AM and determined that R1 was actively transitioning, which the family was notified at around 2:00 AM. Interview with the hospice doctor revealed that it is common for individuals with Alzheimer’s to aspirate, but not necessarily a condition of their death. R1’s Death Certificate states cause of death as Cardiopulmonary arrest and Alzheimer’s disease.

It was alleged that facility staff did not seek timely medical attention for R1. Interviews revealed an outside source was notified on October 9, 2019 at approximately 2:00 AM advising that R1 was having difficulty breathing. Investigation revealed that on October 9, 2019 at approximately 7:00 AM, R1 was being evaluated by a hospice nurse. R1 was having difficulty breathing and was given morphine and oxygen. Hospice nurse remained with R1 until R1 passed away on October 9, 2019 at approximately 8:51 AM with family at the resident’s side. Interview with the hospice doctor revealed that aspiration is common for Alzheimer’s individual, and they determined that the resident was actively transitioning, therefore, an ambulance was not needed.

The Department investigated the allegations that staff did not provide food as ordered by physician which resulted in death, and that staff did not seek timely medical attention. Based on observations, review of records, interviews, and outside sources, the investigation did not produce substantial evidence to meet the preponderance of evidence standard; therefore, the allegations are found UNSUBSTANTIATED.

An exit interview was conducted with Administrator via telephone and a copy of this report LIC 9099 along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Val Paraiso via email. An electronic email read receipt confirms the documents were received.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Jonathan C Pineda	TELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021

LIC9099 (FAS) - (06/04)

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