374604134-9-18-2023-08-AS-SJAB-CVWU3T-20230922151405

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604134
Report Date: 09/18/2023
Date Signed: 09/18/2023 01:11:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/10/2020 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20200710144934

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: 117	DATE:	09/18/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Mike McCoy, Executive Director		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff neglected Resident resulting in worsening of pressure injury

INVESTIGATION FINDINGS:

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On 9/18/2023, at about 12:05 PM, Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced visit to deliver investigative findings. After introducing and identifying himself, LPA was granted entry into the facility and met with Mike McCoy, Executive Director, to whom LPA disclosed the findings of the investigation.

On 7/10/2020, it was reported to Community Care Licensing Division (CCLD) that neglect/lack of supervision for Resident 1 (R1) resulted in R1 being admitted to the hospital with an unstageable pressure injury. The Department’s investigation into the above-listed allegation consisted of review of facility and outside source records and interviews with staff and outside sources.

Interviews with facility staff revealed that R1 was admitted to Pacific Senior Living-Vista on 05/13/19. On 05/08/19, R1 was assessed by a hospice agency. R1 was provided a Plan of Care and began receiving hospice services prior to moving into Pacifica Senior Living-Vista. Records indicate R1 did not have pressure injuries at the time of admittance.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

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-20200710144934

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: PACIFICA SENIOR LIVING VISTA	FACILITY NUMBER: 374604134
	VISIT DATE: 09/18/2023

NARRATIVE

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Interviews with internal and external sources indicate that the hospice agency disseminated information to facility care staff, who followed the agency’s directions and R1’s Plan of Care.

On 10/08/19, R1 was diagnosed with pressure injuries on their coccyx (Stage I and Stage II). A dressing was applied weekly to the affected areas. Records reflect that on 05/19/2020, one of R1’s pressure injuries transitioned to Stage III. Hospice and facility care staff increased position changes to provide perineal care every two hours. Records reveal that, on 06/02/20, one of R1’s pressure injuries degraded to Stage IV.

Records and interviews with staff and outside sources reported that R1 was not compliant with repositioning and often removed protective pillows arranged to elevate the affected areas. It is noted that CCLD regulations permit residents with a terminal diagnosis and are receiving hospice care to remain at a facility if they develop prohibited conditions, such as a Stage IV pressure injury.

Records also noted that R1 had an advance directive. The directive noted that the hospice agency and facility care staff would apply a cooperative and integrated plan of care and document the services provided by whom and at what frequency. The facility staff received training from the hospice agency regarding R1’s expected course of illness and symptoms of their impending death. Notes reflect that the hospice agency kept facility staff informed on the care and proper procedures of R1’s wound care and how to reposition R1 every two hours. A review of R1’s progress notes illustrated that facility and hospice staff documented R1’s repositioning.

The Department has investigated the allegation that because of neglect/lack of supervision R1 was admitted to the hospital with an unstageable pressure injury. This investigation yielded no corroboration or evidence to show that facility staff failed to rotate or reposition R1 in a neglectful manner, causing the pressure injury to degrade to Stage IV. Therefore, the allegation of neglect/lack of supervision is Unsubstantiated.

An exit interview was conducted with Director McCoy and a copy of this report was provided to Mr. McCoy, whose signature below confirms receipt of copies of this report and Licensee Rights (LIC 9058).

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023

LIC9099 (FAS) - (06/04)

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