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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800333
Report Date: 03/28/2023
Date Signed: 03/28/2023 10:23:54 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2023 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20230307112140
FACILITY NAME:C.A.L.L.-PALOMAR HOUSEFACILITY NUMBER:
405800333
ADMINISTRATOR:RANDYN TORRESFACILITY TYPE:
735
ADDRESS:8902 PALOMARTELEPHONE:
(805) 462-2421
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 6DATE:
03/28/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Randyn Torres, AdministratorTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Facility retained client with a prohibited health condition
INVESTIGATION FINDINGS:
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On 3/28/23 at 10:00 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced follow-up visit to deliver final findings. LPA met with Randyn Torres, Administrator, and explained the purpose of the visit.
On the allegation, “Facility retained client with a prohibited health condition,” the complainant’s concern was that Client 1 (C1) had a pressure injury that was a prohibited health condition, and that C1 needed a higher level of care.
LPA interviewed staff on 3/15/2023 from 10:02am to 11:20am, and reviewed relevant documents. C1 was admitted to the hospital on 1/13/23 for seizures, and was released back to the facility on 1/23/23. When C1 returned to the facility, C1 had a “non-pressure injury” and “blood blister,” and wound care and home health were ordered. The discharge notes indicated to take C1 to the outpatient wound care clinic in 3 weeks if the wound did not heal.

Continued on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
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 3
Control Number 29-AS-20230307112140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L.-PALOMAR HOUSE
FACILITY NUMBER: 405800333
VISIT DATE: 03/28/2023
NARRATIVE
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Staff took C1 to the outpatient wound care clinic after the 3 week period on Wednesdays, and home health came to the facility Monday and Friday for wound care.

LPA reviewed documentation from the wound care clinic visits. Documentation from 2/22/23 indicates C1 had a “pressure wound to coccyx.” Records indicate the wound at the beginning of the visit was a Stage 2 pressure injury that was not healed. The 2/22/23 records indicate a physician debrided the wound, and in post debridement the wound was a Stage 3 pressure injury.

LPA reviewed documentation from the 3/1/23 wound care clinic visit. The records indicate at the beginning of the visit, the wound was a Stage 2 pressure injury, a physician debrided the wound, and post debridement the wound was a Stage 3 pressure injury.

LPA reviewed documentation from the 3/8/23 wound care clinic visit. The records indicate at the beginning of the visit, the wound was a Stage 2 pressure injury, a physician debrided the wound, and post debridement the wound was a Stage 3 pressure injury.

Administrator stated on 3/23/23 that C1 saw the wound care physician on 3/22/23 and the physician felt the facility could care for the wound. On 3/23/23, C1 saw their Primary Care Physician (PCP), who confirmed the pressure injury was a Stage 3 sacral wound.

Based on the information obtained, the allegation is deemed substantiated at this time.

Exit interview, deficiency cited on 9099-D, report given, appeal rights given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230307112140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: C.A.L.L.-PALOMAR HOUSE
FACILITY NUMBER: 405800333
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2023
Section Cited
CCR
80091(a)(4)
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80091(a)(4) Prohibited Health Conditions. In adult CCFs clients who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained: Stage 3 and 4 dermal ulcers. This requirement is not met as evidenced by:
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Administrator agrees to submit an exception request for C1 by 3/29/23.
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Based on interviews and record review, the facility did not comply with the above cited section when they retained C1 with a stage 3 pressure injury, which posed an immediate health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3