392700473-11-4-2020-27-AS-KHOS-BV8MD6-20201110083036

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700473
Report Date: 11/03/2020
Date Signed: 11/04/2020 10:14:19 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2020 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200320132351

FACILITY NAME:	MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC		FACILITY NUMBER:	392700473
ADMINISTRATOR:	CATHERINE OTTE		FACILITY TYPE:	740
ADDRESS:	430 NORTH UNION RD		TELEPHONE:	(209) 823-0164
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY:	84	CENSUS: 53	DATE:	11/03/2020
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Catherine Otte, Executive Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff neglect led to resident sustaining pressure injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bruce Jacobs contacted the facility to conclude a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. Telephone call made to this facility on 3/24/2020 and this LPA was able to speak with the facility designated Administrator Catherine Otte who was interviewed. Current census was 53 residents. This investigation consisted of a review of medical records from Doctor’s Hospital of Manteca, a review of home health treatment records from Rehab Focus of Stockton and the facility's records including the Physician’s Report (LIC 602) and care plan. Interviews were conducted with facility management, staff and other witnesses were contacted.

The complaint alleges that facility neglect led to resident sustaining a pressure injury The investigation concluded that the resident (R-1) moved into the Assisted Living Facility on 02/19/20 and was already receiving wound care. The resident was seen by Home Health on a regular basis for care of Stage 1 and 2 pressure injuries to her buttocks. The care plan indicated R-1 should be repositioned, transferred and assisted with toileting. The Administrator stated that on 3/19/20 the resident was sent to the hospital as her wounds had worsened.

Continued.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

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 4

Control Number 27-AS-20200320132351

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC	FACILITY NUMBER: 392700473
	VISIT DATE: 11/03/2020

NARRATIVE

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LPA Jacobs interviewed additional care staff who indicated they notified the Resident Care Coordinator two or three times over two or three days that an odor was coming from the resident’s wounds before the resident was sent out for evaluation.

LPA also interviewed other care staff who indicated they did not see the wounds but noticed a bad smell coming from R1. As a result, a Stage 3 pressure injury was sustained. The resident was diagnosed as having an unstageable pressure injury to her left hip when admitted to the hospital and this injury was later assessed as a Stage 3 pressure injury. Interviews with the Administrator revealed that the home health agency nurse would not leave visit records, however, the facility failed to seek timely medical care for the resident after staff expressed their concerns The resident was discharged from the hospital, returned to the facility and has subsequently moved to skilled nursing as needing a higher level of care.

As a result of this investigation, the Department has determined the above allegation is (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6.

At the time of the conclusion of this complaint investigation, the issuance of a Civil Penalty was still being determined. However, the Licensee was informed that a Civil Penalty may be assessed based on Health & Safety Code section 1569.49.

Exit interview conducted and report provided. Appeals rights printed

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20200320132351

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC	FACILITY NUMBER: 392700473
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/03/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/11/2020 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as	1 2 3 4 5 6 7	Plan of Correction: Facility Administrator will develop a training and staffing plan to ensure staff is sufficiently trained on the resident's care plan and the plan is followed. Also, care staff are properly trained to perform their basic duties to meet the residents' needs. In addition, the facility will develop a plan to ensure that that residents are reassessed as required
	8 9 10 11 12 13 14	evidenced by: Resident (R-1) was accepted into the Assisted Living Facility on 02/19/20 and sent to the hospital on 03/19/20. At the hospital the resident was diagnosed with an Unstageable pressure injury to the hip and later discharged and accepted back into the to the facility. Facility staff noticed an odor coming from the wounds and it was two to three days after observing the odor before the resident was sent out and this poses an immediate health risk to residents in care.	8 9 10 11 12 13 14	when there is a change in their condition. A written Plan of Correction detailing how the facility will implement an adequate procedure to assess and meet the resident's need. In addition, it is noted the Resident Care coordinator is no longer employed by the facility. POC due by 11/11/20 and completion of training due within 30 days.
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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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2020 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200320132351

FACILITY NAME:	MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC		FACILITY NUMBER:	392700473
ADMINISTRATOR:	CATHERINE OTTE		FACILITY TYPE:	740
ADDRESS:	430 NORTH UNION RD		TELEPHONE:	(209) 823-0164
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY:	84	CENSUS: 53	DATE:	11/03/2020
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Catherine Otte, Executive Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Illegal eviction

INVESTIGATION FINDINGS:

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LPA Bruce Jacobs contacted Executive Director Cathy Otte by phone to discuss and complete this complaint investigation and provide findings regarding the allegation listed above. The investigation was conducted by LPA Jacobs and consisted of a review of facility records and interviews with facility management and staff. Other witnesses were contacted.

The complaint alleges that the facility refused to accept a resident (R-1) back into the facility after a hospital stay. The investigation concluded, based on interviews and record reviews, that the resident was sent to the hospital for evaluation and treatment. The facility and the hospital had conversations regarding the condition and discharge of resident and if the facility was capable of accepting the client back into the community. At the time of the original planned discharge date as the resident was diagnosed with a prohibited condition and the facility applied for an exception with Licensing. When the resident was discharged, she was accepted back to the facility.

There is not sufficient evidence to prove with a preponderance that the above allegation is valid and therefore, the allegation is determined to be UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

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 4