374604347-8-14-2023-08-AS-DPOL-CV8RVS-20230831132202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604347
Report Date: 08/14/2023
Date Signed: 08/14/2023 09:46:08 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
12/14/2021 and conducted by Evaluator Marisela Garcia-Centeno

COMPLAINT CONTROL NUMBER: 08-AS-20211214104556

FACILITY NAME:	SUNSET COAST ASSISTED LIVING		FACILITY NUMBER:	374604347
ADMINISTRATOR:	TAPIA, PATRICIA		FACILITY TYPE:	740
ADDRESS:	808 THERMAL AVE		TELEPHONE:	(619) 882-5003
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92154
CAPACITY:	6	CENSUS: 4	DATE:	08/14/2023
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Caregiver, Leticia Castro Guizar		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff neglect resulting in worsening pressure injuries
Staff did not follow resident's care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA was greeted by Caregiver, Leticia Castro Guizar to whom she identified herself. Administrator, Patricia Tapia joined the meeting via conference call and LPA shared findings.

The Department investigated the above-listed complaint allegations. The investigation consisted of an inspection of the facility, observations, multiple interviews with residents, staff, and outside sources, and a detailed review of resident records, including medical records, chronological medical care, and service care plans.

On December 14, 2021, Community Care Licensing (CCL) received a complaint alleging that facility staff neglect resulted in the worsening of pressure injuries for a resident (R1) in care. It was also alleged that facility staff did not follow the resident’s care plan for the same resident in care. [an LIC 811 Confidential Names List was provided to staff to identify the resident].
(continue at LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

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-20211214104556

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNSET COAST ASSISTED LIVING	FACILITY NUMBER: 374604347
	VISIT DATE: 08/14/2023

NARRATIVE

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(Continue from LIC 9099)
A detailed review of R1’s records indicated that R1 had a primary diagnosis of Alzheimer’s disease, as well as other serious illnesses, and was experiencing chronic pain when they were admitted to the facility on August 31, 2021. In addition, R1 was under medical care by an outside medical provider. On August 30, 2021, before R1 was discharged from the hospital and placed at the facility, a referral for routine home care was established by an outside provider to treat existing pressure injuries. In addition, the attending physician ordered and initiated antibiotics to treat the pressure injuries as well as a hospital bed with a low air loss mattress. A Licensed Vocational Nurse (LVN) reported that R1 had an ulcer on their coccyx when they arrived at the facility. A review of records of the care and supervision provided by staff as well as the outside medical provider indicated that R1’s service care plans were coordinated between facility staff and the outside medical provider. The records review and multiple interviews with staff and outside sources indicated that medical care was executed as prescribed to meet R1’s care needs. Medical records indicated that R1 had been receiving wound care since September 20, 2021. Facility documentation confirmed that staff were rotating R1 every two hours. The physician’s progress notes indicated that R1’s wound incidence was unavoidable due to R1’s advanced age and other pre-existing health conditions. The LVN continued to provide wound care three times per week. However, despite the routine and consistent medical attention provided, on December 13, 2021, at the request of facility staff, R1 was transported to the hospital to treat a possible wound infection. R1 was discharged back to the facility on December 18, 2021, with continued home care by an outside medical provider. R1’s medical team as well as responsible parties agreed to discharge R1 back to the facility with comfort care and antibiotics. Multiple interviews with staff and outside sources and a review of records confirmed that the staff adhered to R1’s service care plan and medical treatment recommendations.

The Department has investigated the allegations and has found that there was insufficient evidence to corroborate the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, these allegations are deemed to be unsubstantiated.

An exit interview was conducted with Caregiver, Guizar and Administrator, Tapia, and a copy of this report, Confidential Name List (LIC 811), along with Licensee/Appeal Rights (LIC 9058 03/22) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno	TELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

LIC9099 (FAS) - (06/04)

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