374604177-10-14-2021-08-AS-IESA-C8A4ZN-20211029193302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604177
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:19:18 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
09/21/2020 and conducted by Evaluator Adam Hamer

COMPLAINT CONTROL NUMBER: 08-AS-20200921101338

FACILITY NAME:	ATRIA BONITA		FACILITY NUMBER:	374604177
ADMINISTRATOR:	WILLIAMS, REBECCA		FACILITY TYPE:	740
ADDRESS:	3434 BONITA ROAD		TELEPHONE:	(619) 476-9444
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY:	145	CENSUS: 97	DATE:	10/14/2021
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Julia Lopez, Administrator		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Resident sustained multiple fractures while in care.
Facility did not report changes in resident's condition to resident’s responsible party.
Facility did not did report a change in resident’s condition to a physician in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced complaint investigation visit on today's date. LPA was greeted at the front entrance, was granted entry after identifying himself and disclosing the purpose of the visit, which was to deliver findings for this complaint investigation. LPA later met with Administrator Julia Lopez to deliver the findings.

The Department’s investigation included interviews with staff and outside sources. Facility records and outside source medical records were also obtained by the Department and reviewed for pertinent evidence.

The Department received a complaint on September 21, 2020 alleging that a resident (R1)(see Confidential Names List – LIC 811) sustained multiple fractures while in care, that facility did not did report a change in R1’s condition to a physician in a timely manner and did not report changes in R1’s condition to resident’s responsible party. Interviews with facility staff and outside sources revealed that R1 sustained two unwitnessed falls on June 29, 2020 and July 20, 2020 while inside their apartment at the facility. R1 was able to communicate, was independent and was able to move around using a walker, wheelchair and motorized scooter without facility staff assistance. The first fall occurred when R1 was bending down to get something, fell and landed on their right side. R1 was not injured or transported to the hospital after this fall, and facility staff were not made aware of the fall.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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-20200921101338

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: ATRIA BONITA	FACILITY NUMBER: 374604177
	VISIT DATE: 10/14/2021

NARRATIVE

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The second fall was an unwitnessed fall in R1’s bedroom and occurred when R1 was using their walker, turned around too fast, lost their balance and fell. R1 was taken to the hospital, was diagnosed with a fracture and spent one week in the hospital followed by rehabilitation. Prior to the time of the falls, the facility had given R1 a pendant to call for staff assistance, but they never used it. Also, facility records and interviews revealed that facility staff would check on R1 three times per shift. Since facility staff were not aware of and could not have prevented R1’s falls, they did not result due to facility staff’s neglect or lack of supervision.

With regard to the allegations that facility did not ensure changes in R1’s condition were reported to a physician in a timely manner and did not report changes in R1’s condition to R1’s responsible party, an outside source who visited them on August 18, 2020 saw that they were dehydrated and took them to the hospital for evaluation. R1 was later diagnosed with a urinary tract infection (UTI) and was treated. Prior to the outside source visiting R1, after facility staff observed that R1 was becoming more confused, on August 17 and August 18, 2020, outside medical staff had tried to obtain a urine sample for a urinalysis to rule out UTI, but they were unsuccessful. Facility staff then planned to obtain a catheter sample on August 18, 2020 and communicated this to R1’s responsible party. Also, the facility had previously contacted R1’s responsible party and told them that R1 refused to allow facility staff to allow incontinence assistance and use incontinence products correctly, and would refuse to be bathed, which may have contributed to the UTI. Although responsible party denied that the facility communicated this to them, and that services were offered by the facility and subsequently refused, outside source records corroborate facility having communicated this to R1’s responsible party.

Prior to R1 going to the hospital on August 18, 2020, facility staff had ordered a urinalysis when they saw possible signs of UTI, R1 never complained of not getting enough water or any pain or discomfort. Also, earlier in the day on August 18, 2020, when outside source medical professional had checked R1’s vitals, they were within normal range, and R1 did not complain of any pain, distress or discomfort at that time. Since there was no indication that R1’s condition had changed to the point that they needed immediate medical attention, facility did not call 911 and did not report a change in condition to a physician at that time.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200921101338

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: ATRIA BONITA	FACILITY NUMBER: 374604177
	VISIT DATE: 10/14/2021

NARRATIVE

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Based on the evidence obtained during the complaint investigation, the allegations that R1 sustained multiple fractures while in care, that facility did not did report a change in R1’s condition to a physician in a timely manner and did not report changes in R1’s condition to resident’s responsible party are found to be UNSUBSTANTIATED, as there is not a preponderance of the evidence to prove that the allegations occurred. An exit interview was conducted with Ms. Lopez, and a copy of this report, the LIC 811 and Licensee/Appeal Rights (LIC 9058 – FAS 01/16) were emailed to her; she expressed that she would send LPA a confirmation upon receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Adam Hamer	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC9099 (FAS) - (06/04)

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