374604294-5-23-2023-18-AS-JESL-CTB3ZM-20230630184147

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604294
Report Date: 05/23/2023
Date Signed: 05/23/2023 01:00:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/09/2022 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20221209153932

FACILITY NAME:	LAS VILLAS DEL NORTE		FACILITY NUMBER:	374604294
ADMINISTRATOR:	FARISH, JOLENE		FACILITY TYPE:	740
ADDRESS:	1325 LAS VILLAS WAY		TELEPHONE:	(760) 741-1047
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	198	CENSUS: 166	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Ana Cruz, Resident Care Director Klarrisa Romero, Memory Care Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff neglect resulting in resident falling and sustaining a hip fracture
Resident pushed out of wheelchair and sustaining a shoulder fracture

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Resident Care Director Ana Cruz and Memory Care Director Klarrisa Romero and explained the purpose of the visit.
Regarding the allegation “Resident pushed out of wheelchair and sustained a shoulder fracture due to lack of supervision”, it was alleged that Resident #1(R1) was pushed out of their wheelchair by two unknown women resulting in a shoulder fracture. Interview conducted with Memory Care Director Ana Cruz revealed R1 was admitted to the facility in 2019, was ambulatory at times and utilized a wheelchair other times due to personal preference. Review of R1’s Preplacement Appraisal dated 10/13/2019 revealed R1 was able to transfer to and from bed without assistance. Review of R1’s 90 day Level of Care Assessment dated 01/07/2020 and 180 day Level of Care Assessment dated 07/05/2021 revealed R1 was able to transfer independently and required no transport/escort assistance. None of R1’s records reviewed revealed R1 required direct supervision. Review of Resident Incident Report (IR) dated 10/19/2021 revealed R1 suffered an unwitnessed fall in their room on 10/19/2021. Interview conducted with Cruz and review of 10/19/2021 IR (CONTINUED ON LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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 18-AS-20221209153932

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LAS VILLAS DEL NORTE	FACILITY NUMBER: 374604294
	VISIT DATE: 05/23/2023

NARRATIVE

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(CONTINUED FROM LIC9099)
revealed staff found R1 in a sitting position on the floor near the door of their room during rounds. There were no other persons in R1’s room when they were found. R1 was unable to explain to staff what had occurred but did complain of hip and shoulder pain and was transferred to the Palomar Hospital for evaluation where they were diagnosed with a fractured humerus as documented in R1’s Palomar Hospital medical records dated 10/20/2021. Review on 10/19/2021 IR also revealed facility staff responded appropriately, immediately requested medical attention and notified all responsible parties. Interview conducted with a member of R1’s family revealed R1 told a contradictory recollection of the 10/19/2021 incident describing how they threw a facility resident to the floor themselves rather than having been pushed out of their wheelchair. R1 was unable to be interviewed directly.
Regarding the allegation “Staff neglect resulting in resident falling and sustaining a hip fracture”, it was alleged that R1 suffered an unwitnessed fall resulting in a hip fracture which contributed to their passing. Interview conducted with Memory Care Director Ana Cruz and review of Resident Incident Report (IR) dated 09/22/2022 indicated during a status check, R1 was found by staff on the floor of their room on the morning of 09/22/2022. Review of IR dated 09/22/2022 revealed R1 reported they were trying to get up on their wheelchair and fell to the floor. R1 complained of hip and back pain and was transferred to Palomar Hospital for evaluation. Palomar Hospital medical records dated 09/23/2022 indicated R1 was diagnosed with a fractured hip which was surgically repaired. Review of IR dated 09/22/2022 also revealed facility staff responded appropriately, immediately requested medical attention and notified all responsible parties. Review of R1’s Level of Care Assessment dated 07/05/2021 indicated at the time of R1’s fall on 09/22/2022, they were able to independently transfer, required no transport/escort assistance, and had been identified as a fall risk. Interview with Cruz indicated as identified as a fall risk, R1 would receive additional assistance with their Activities of Daily Living (ADLs) and more frequent status checks. None of R1’s records reviewed revealed R1 required direct supervision. Investigation did not reveal documents to corroborate nor refute staff status checks were being conducted. Following R1’s return to the facility, they were placed on hospice and passed away at the facility on 12/02/2022. Interview with R1’s hospice clinician revealed there was no evidence of “anything neglectful” related to R1’s care.
Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

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