374604134-7-30-2020-08-AS-IESA-BS32W2-20200731174450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604134
Report Date: 07/30/2020
Date Signed: 07/30/2020 09:58:28 AM

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
09/26/2019 and conducted by Evaluator Adam Hamer

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20190926163243

FACILITY NAME:	PACIFICA SENIOR LIVING VISTA		FACILITY NUMBER:	374604134
ADMINISTRATOR:	ENCISO, KAREN		FACILITY TYPE:	740
ADDRESS:	760 E BOBIER AVE		TELEPHONE:	(760) 691-1027
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	252	CENSUS: 129	DATE:	07/30/2020
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Karen Enciso, Administrator		TIME COMPLETED:	09:20 AM

ALLEGATION(S):

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9

Facility staff caused injury to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced complaint investigation tele-visit via FaceTime due to COVID-19. LPA gained access to the facility, identified himself, spoke with Karen Enciso and discussed the purpose of the visit, which was to deliver findings for the above allegation.

The Department’s investigation included, but was not limited to, interviews with staff and outside sources. Facility and medical records and photographs were also obtained by the Department and reviewed for pertinent evidence.

The Department received a complaint alleging that facility staff neglect caused an injury to Resident #1 (R1) (See LIC 811 Confidential Names List). Interviews with staff and outside sources and a records review revealed that, in September 2019, one (1) facility staff member lifted R1 from their wheelchair onto their feet to get them into bed. Staff admitted that they had failed to read the care plan for R1 which showed that R1 required two (2) staff members to transfer them. When staff lifted R1 by their pants and began to transfer R1, R1 fell to their knees which caused injury to the area below both of R1’s knees. A review of facility and medical records revealed that R1 had a fall in July 2019 that resulted in a scrape to their knee. Pictures the Department reviewed of R1’s legs showed dark marks that appeared to be bruises below both knees, and another mark on their right knee.

Based on the evidence obtained from interviews and records review, the allegation that facility staff caused injury to resident in care is found to be SUBSTANTIATED, as there is a preponderance of the evidence to prove that the allegation occurred. A citation is being issued in accordance with California Code of Regulations, Title 22, and is listed on the LIC9099D. A plan of correction was developed with the Administrator.

An exit interview was conducted via FaceTime, and a copy of this report, and Licensee's Rights (LIC 9058 01/16) were emailed to Ms. Enciso; an email read receipt confirms receipt of these documents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Girolami	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020

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

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
09/26/2019 and conducted by Evaluator Adam Hamer

COMPLAINT CONTROL NUMBER: 08-AS-20190926163243

FACILITY NAME:	PACIFICA SENIOR LIVING VISTA		FACILITY NUMBER:	374604134
ADMINISTRATOR:	ENCISO, KAREN		FACILITY TYPE:	740
ADDRESS:	760 E BOBIER AVE		TELEPHONE:	(760) 691-1027
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	252	CENSUS: 129	DATE:	07/30/2020
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Karen Enciso, Administrator		TIME COMPLETED:	09:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff neglect resulted in resident developing pressure injury.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced complaint investigation tele-visit via FaceTime due to COVID-19. LPA identified himself, met with Administrator, Karen Enciso and discussed the purpose of the tele-visit, which was to deliver findings for the above allegation.

The Department’s investigation included, but was not limited to, interviews with staff, outside sources and resident of the facility. Photographs and facility and medical records were also obtained by the Department and reviewed for pertinent evidence.

The Department received a complaint that facility staff put a resident in a wheelchair for hours which caused pressure injuries on the resident’s buttocks. The evidence shows that Resident 1 (R1) (See Confidential Names List on LIC 811) began hospice services at the facility on May 8, 2019, was assessed by medical professional in May 2019 an found to have pale, dry and fragile skin, that they needed to be turned and repositioned to prevent skin breakdown, and that ointment cream needed to be applied to any affected area(s).

Staff statements during the Department’s interviews were inconsistent as to their knowledge of R1’s pressure injury. One staff first observed an existing pressure injury on R1’s buttocks on September 24, 2019, while other staff claimed that they first learned of a Stage 3 pressure injury on R1’s buttocks sometime in late 2019, after being notified by hospice. Other staff denied seeing or having knowledge of any pressure injury to R1’s buttocks. Staff made sure to reposition R1 at least every two hours, put a pillow under them for cushioning and applied cream to them at the direction of medication technicians. Outside source interview revealed that they were informed by facility staff that R1 had a Stage 1 and Stage 2 pressure injury sometime prior to October 3, 2019, that R1 was on hospice at that time and that the pressure injuries were healing. Department’s interview with resident revealed that caregivers repositioned them often, always responded to them right away and put skin cream on them.

Medical records reveal that there were no pressure injuries noted through early September 2019, that R1 had the onset of Stage 1 and Stage 2 pressure injuries on their buttocks on September 24, 2019, that a hospice nurse provided wound care to their left and right buttocks area on October 4, 2019, and there were no open areas at that time. Facility charting records reveal that, per medical professional’s orders, staff applied cream on R1’s buttocks from early July 2019 through the end of September 2019, and repositioned them on certain days every 2 hours. The hospice care plan for R1 included implementing preventative measures such as heel protectors, elbow pads, and specialized mattress or pads for skin integrity, to evaluate skin integrity every visit, and order wound care as needed. Records also show that on September 25, 2019 facility staff received in-service training on skin care which aimed to teach staff the promotion of good skin integrity and wound healing practices. The Department also reviewed pictures of R1’s buttocks area which revealed some markings and/or scabbing near the middle of the buttocks area, between the two cheeks; there did not appear to be any open wounds or other serious injuries. Medical records did not show that the injury on R1’s buttocks progressed to a Stage 2 pressure injury.

Based on the evidence obtained from the complaint investigation, staff attempted to take preventative measures as ordered by medical professionals to mitigate R1’s skin breakdown and said attempts may have prevented the injury from developing into a more serious pressure injury. The allegation that staff’s neglect on R1 resulted in resident developing a pressure injury is found to be UNSUBSTANTIATED, as there is not a preponderance of evidence to show that the allegation occurred.

An exit interview was conducted, and a copy of this report, and Licensee's Rights (9058 01/16) were emailed to Ms. Enciso. An email read receipt confirmation confirms receipt of these documents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Girolami	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20190926163243

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: PACIFICA SENIOR LIVING VISTA	FACILITY NUMBER: 374604134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/11/2020 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.	1 2 3 4 5 6 7	Licensee agreed to provide training to staff regarding reviewing care plans for all residents and providing services appropriate to the conditions and needs of the residents. Licensee agreed to submit the following documents to
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and records review, licensee did not provide the care to meet R1’s needs, which resulted in R1 sustaining leg injuries, which posed an immediate health risk to R1.	8 9 10 11 12 13 14	CCLD by the POC date: certificate of completion for each staff member for said training.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Girolami	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020

LIC9099 (FAS) - (06/04)

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