374604288-3-15-2021-08-AS-RHEK-BZN25W-20210331170613

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604288
Report Date: 03/15/2021
Date Signed: 03/15/2021 05:18:55 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
10/05/2020 and conducted by Evaluator Dawn Segura

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20201005151016

FACILITY NAME:	CADENCE AT POWAY GARDENS - THE PALMS		FACILITY NUMBER:	374604288
ADMINISTRATOR:	BOTTOM, JASON		FACILITY TYPE:	740
ADDRESS:	12708 MONTE VISTA RD		TELEPHONE:	(800) 811-9595
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	24	CENSUS: 12	DATE:	03/15/2021
		UNANNOUNCED	TIME BEGAN:	02:09 PM
MET WITH:	Julie Bagg, VP of Operations, West		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Lack of supervision resulted in resident's death.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dawn Segura contacted Julie Bagg, VP of Operations, West (VP), via video conference, due to COVID-19, to deliver investigative findings. LPA identified herself and discussed the purpose of the call with the VP.

Community Care Licensing (CCL) has investigated the above listed complaint allegation. The Department’s investigation consisted of a review of facility records, review of resident medical records, outside source records, and interviews of facility staff and outside sources.

Evidence indicates that Resident 1 (R1) [licensee was provided an LIC 811 Confidential Names List that identifies the resident] resided in Cadence at Poway Gardens facilities from 2/10/2020 until the time of the incident which is the subject of this investigation. R1 moved into Cadence at Poway Gardens-The Sycamores (Sycamores) on 2/10/2020. A Physician’s Report completed shortly after R1’s admission into the facility documents that R1 had wandering behavior and required supervision. Additional evidence reflects that

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021

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-20201005151016

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: CADENCE AT POWAY GARDENS - THE PALMS	FACILITY NUMBER: 374604288
	VISIT DATE: 03/15/2021

NARRATIVE

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while R1 resided in the Sycamores, facility staff became aware that R1 had exit seeking behaviors and required a high level of supervision. On one occasion, R1 exited the gate of the Sycamores, but was stopped by staff before having an opportunity to leave the grounds of the facility.

As a result of R1’s exit seeking behaviors, it was suggested by facility administration that R1 be relocated to Cadence at Poway Gardens-The Palms (Palms), as it offered more security and a higher level of supervision. R1’s family and physician agreed, and on 9/16/2020, R1 was moved to the Palms. On 9/10/2020, shortly before transfer to the Palms, R1’s care plan was updated and indicated that R1 had extensive wandering issues, that R1 would wander and leave immediate area, get lost, or be combative about returning. It was also documented in the plan that R1 required supervision; however, staff interviews revealed inconsistencies in understanding of the level of supervision required by staff to meet R1’s needs.

Records and interviews reveal that on 9/27/2020, between 7:35 AM and 8:26 AM, while staff were preparing for breakfast, R1 was sitting in the dining room of the Palms. At 8:26 AM, R1 left the dining area and used a walker to walk down the hallway. At 8:30 AM, R1 exited through the door leading onto the facility’s patio. Between 8:30 AM and 8:45 AM, surveillance camera captured images of R1 walking into different areas of the patio. Records indicate that between 8:45 AM and 9:00 AM, R1 was not seen on surveillance camera, nor was R1 seen by any staff. At 9:00 AM, when staff began to serve breakfast in the dining area, staff noticed and became aware that R1 was not present. Staff began to look for R1 inside the facility and proceeded to look in the patio area. After R1 was not found in the patio area, evidence indicates that staff exited the gate from the enclosed patio and, at 9:03 AM, found R1 lying on the concrete ground near the entrance into the underground parking garage located adjacent to the facility. The report generated by the Poway Fire Department EMS Unit that arrived on the scene, treated, and transported R1 indicates that R1 fell approximately 15 feet.

Evidence shows that R1 was transported to a local hospital, admitted at 9:37 AM on 9/27/2020, and was subsequently assessed to have a left fibular fracture and sacral fracture, closed. Records further show that R1 remained in the hospital, experienced multiple seizures and acute deterioration following the injuries, and passed away on 10/3/2020. According to the County of San Diego Death Certificate, R1’s cause of death was identified as complications of blunt force injuries.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20201005151016

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: CADENCE AT POWAY GARDENS - THE PALMS	FACILITY NUMBER: 374604288
	VISIT DATE: 03/15/2021

NARRATIVE

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Based on evidence obtained during the course of the investigation, facility staff were not aware of R1’s whereabouts for up to 30 minutes, despite R1’s documented wandering behavior and need for supervision. Additionally, while unsupervised, R1 had the time and ability to elope from a secured area and sustain a fall that ultimately lead to R1’s death. Accordingly, the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. The deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. At this time, pursuant to Health and Safety Code Section 1569.49, a civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.

An exit interview was conducted, via virtual visit, and a copy of this report and Licensee/Appeal Rights (LIC 9058 01/16) were provided to Julie Bagg, VP of Operations, West, via electronic mail. An electronic read receipt confirmation was requested to be sent by Julie Bagg upon receipt of the documents.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20201005151016

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: CADENCE AT POWAY GARDENS - THE PALMS	FACILITY NUMBER: 374604288
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 03/16/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	VP offered to provide proof of staff training regarding elopement and facility protocol to CCL by 3/16/21. A barrier was erected to block the area from which R1 eloped and blocks surrounding areas to mitigate the immediate risk. VP offered to provide a date for staff training on resident supervision by
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not provide supervision needed to ensure the safety of R1, 1 of 20 residents in care, who eloped and sustained injuries leading to death. This posed an immediate safety risk to resident in care.	8 9 10 11 12 13 14	3/16/21 and provide proof of training to CCL by 3/26/21. VP offered to discuss changes to the facility's policy regarding elopement and staff supervision of residents and exterior modifications to the patio area w/executive level staff and report results of those discussions to CCL by 3/19/21.
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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: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021

LIC9099 (FAS) - (06/04)

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