374604454-5-31-2024-08-AS-LTEZ-D5T24D-20240531170346

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604454
Report Date: 05/31/2024
Date Signed: 05/31/2024 01:41:52 PM

Unsubstantiated

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
08/21/2023 and conducted by Evaluator Dawn Segura

COMPLAINT CONTROL NUMBER: 08-AS-20230821153534

FACILITY NAME:	HUNTINGTON MANOR		FACILITY NUMBER:	374604454
ADMINISTRATOR:	DERAFERA, TESS		FACILITY TYPE:	740
ADDRESS:	14755 BUDWIN LN		TELEPHONE:	(619) 625-6886
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	21	CENSUS: 20	DATE:	05/31/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Tess Derafera, Administrator		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Neglect resulted in stage 4 pressure injury.

Neglect resulted in multiple stage 2 pressure injuries.

Licensee did not seek timely medical attention for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Tess Derafera, Administrator, to whom LPA disclosed the reason for the visit.

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

It was reported to Community Care Licensing that Resident 1 (R1) developed a stage 4 pressure injury and multiple stage 2 pressure injuries due to neglect by facility staff. According to evidence obtained during the investigation, R1 moved into the facility on 2/28/2020. In addition to services provided by facility staff, R1 hired two personal nurses (PN 1 and PN 2), as R1 required full assistance in care.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 08-AS-20230821153534

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: HUNTINGTON MANOR	FACILITY NUMBER: 374604454
	VISIT DATE: 05/31/2024

NARRATIVE

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On 7/7/2023, R1 started receiving hospice services. R1 continued to receive services from his/her two private nurses. Records reflect that on or about 8/5/2023, a hospice nurse noted that a red area was developing on R1’s buttocks. At the time of the observation, PN 2 was present and made aware of the red area. The nurses treated the area and decided to monitor it. On 8/17/2023, PN 1 was contacted by a hospice nurse and facility staff regarding the red area on R1’s buttocks. PN 1 informed the nurse and staff that he/she was out of town and provided instruction as to how to clean the wound. PN 1 made the nurse aware that he/she would be back that night and check and reevaluate the next day. The hospice nurse noted that upon assessing the red area, the wound was closed. The skin was peeled off from cleaning, and R1’s buttocks appeared to have a light yellow film. There was no drainage or sign of bleeding at the time. R1’s physician was made aware of the wound through photos that were sent by PN 1 and facility staff.

On 8/18/2023, at or about 1:00 PM, PN 1 visited R1 and tended to R1’s wound. PN 1 was not aware that there was a deep abscess in the area and began to compress on it, at which time it excreted pus and bodily fluid. At this time, PN 1 called 911, paramedics arrived, and R1 was transported to a local hospital. Hospital records note that the physician reported the chief complaint to be an area of infection with purulent drainage to the right buttock. On 8/30/2023, R1 was discharged from the hospital to a skilled nursing facility.

Interview of R1’s physician, conducted during the investigation, revealed that the abscess was unforeseen, and the facility’s caregivers had nothing to do with the development of the abscess. R1’s physician noted that R1’s complex medical conditions caused the abscess to develop without symptoms. R1’s physician made it clear that R1 did not have a pressure injury on the buttocks, as was reported, but had an abscess. R1’s physician also noted that facility staff communicated with the physician, as needed, regarding any questions or concerns relative to R1’s care, and facility staff provided excellent care to R1. One of R1’s hospice nurses also noted that the facility’s caregivers were well trained, provided extra care, did a really good job, and were able to take care of R1 with all the services he/she required.

Relative to the report of R1 sustaining multiple stage 2 pressure injuries on ankles and feet, records reviewed during the investigation indicate that water blisters had developed on R1’s hands and feet; however, there was no evidence obtained to indicate that R1 sustained pressure injuries in any of those areas.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 08-AS-20230821153534

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: HUNTINGTON MANOR	FACILITY NUMBER: 374604454
	VISIT DATE: 05/31/2024

NARRATIVE

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The third allegation is that R1 did not receive timely medical attention. According to evidence obtained during the investigation, R1 had been receiving frequent care from hospice nurses and his/her private nurses, PN1 and PN 2. Prior to PN 1 compressing on the area that was later determined to be an abscess, there was no indication to facility staff that R1 had a sudden need for medical attention. At the time that PN 1 compressed and expressed fluid from the abscess, R1’s condition worsened which triggered the need for medical attention. At that time, PN 1 called 911 and had R1 transported to the hospital for medical care.

Based on all of the foregoing, the above listed allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with Tess Derafera, and copies of this report and Licensee/Appeal Rights (LIC 9058) were provided to the administrator at the conclusion of the visit. Administrator’s signature on this report acknowledges receipt of copies of the rights and report.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
08/21/2023 and conducted by Evaluator Dawn Segura

COMPLAINT CONTROL NUMBER: 08-AS-20230821153534

FACILITY NAME:	HUNTINGTON MANOR		FACILITY NUMBER:	374604454
ADMINISTRATOR:	DERAFERA, TESS		FACILITY TYPE:	740
ADDRESS:	14755 BUDWIN LN		TELEPHONE:	(619) 625-6886
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	21	CENSUS:	DATE:	05/31/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:			TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Staff did not notify resident's responsible party of change in condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Tess Derafera, Administrator, to whom LPA disclosed the reason for the visit.

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

It was reported to Community Care Licensing that facility staff did not notify Resident 1’s (R1) responsible party of a change in R1’s condition. According to evidence obtained during the investigation, R1 moved into the facility on 2/28/2020. In addition to services provided by facility staff, R1 hired two personal nurses (PN 1 and PN 2), as R1 required full assistance in care, and on 7/7/2023, R1 started receiving hospice care.

Unfounded

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20230821153534

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: HUNTINGTON MANOR	FACILITY NUMBER: 374604454
	VISIT DATE: 05/31/2024

NARRATIVE

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Records reflect that on or about 8/5/2023, a hospice nurse noted that a red area was developing on R1’s buttocks. At the time of the observation, PN 2 was present and made aware of the red area. The nurses treated the area and decided to monitor it. On 8/18/2023, PN 1 visited R1 and tended to R1’s wound. PN 1 was not aware that there was a deep abscess in the area and began to compress on it, at which time it excreted pus and bodily fluid. At this time, PN 1 called 911, paramedics arrived, and R1 was transported to a local hospital. Hospital records note that the physician reported the chief complaint to be an area of infection with purulent drainage to the right buttock.

The investigation did not yield evidence to conclude that there was a change in R1’s condition until PN 1 compressed the abscess which excreted bodily fluids in response to the compression. Records reviewed and interviews conducted during the investigation revealed that PN 1 has been granted durable power of attorney by R1. Accordingly, if notification was to be provided, it would have been provided to PN 1, who was present and actively involved when the identified change in R1’s condition occurred.

Based on the foregoing, we have found that the complaint allegation is unfounded, meaning that the allegation is without a reasonable basis. Therefore, as to the above listed allegation, the facility is in compliance with Title 22 regulations at this time, and we have dismissed the complaint.

An exit interview was conducted with Tess Derafera, Administrator, and copies of this report and Licensee Rights (LIC 9058) were provided to the administrator at the conclusion of the visit. Administrator's signature on this report acknowledges receipt of copies of the rights and report.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5