405800361-7-17-2023-29-AS-KBUY-CU6P62-20230728110134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800361
Report Date: 07/17/2023
Date Signed: 07/17/2023 03:29:40 PM

Unfounded

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
01/26/2023 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20230126152418

FACILITY NAME:	WYNDHAM RESIDENCE		FACILITY NUMBER:	405800361
ADMINISTRATOR:	JODI BELTRAMA		FACILITY TYPE:	741
ADDRESS:	222 S. ELM STREET		TELEPHONE:	(805) 474-7260
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	72	CENSUS: 52	DATE:	07/17/2023
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Jodi Beltrama		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Questionable death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA De Leon met with and explained the reason for the visit.

On 01/26/2023, the Department received a complaint regarding allegations of questionable death of two residents and staff did not provide proper medication assistance to resident in care. It was alleged that Staff #1 (S1) was providing morphine to Resident #1 (R1) and Resident #2 (R2) and S1 is not able to do so. It was alleged that S1 provided morphine to R1 when it was not needed and R1 passed away within days of getting morphine medication, and the reporting believed R1 was not getting comfort medications from hospice. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Romelia Munoz.

Continued 9099-C pages

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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 6

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
01/26/2023 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20230126152418

FACILITY NAME:	WYNDHAM RESIDENCE		FACILITY NUMBER:	405800361
ADMINISTRATOR:	JODI BELTRAMA		FACILITY TYPE:	741
ADDRESS:	222 S. ELM STREET		TELEPHONE:	(805) 474-7260
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	72	CENSUS: 52	DATE:	07/17/2023
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Jodi Beltrama		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff did not provide proper medication assistance to residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA De Leon met with Jodi Beltrama Administrator and explained the reason for the visit.

On 01/26/2023, the Department received a complaint regarding allegations that staff did not provide proper medication assistance to resident in care. It was alleged that Staff #1 (S1) was providing morphine to Resident #1 (R1) and Resident #2 (R2) without prescriptions or proper qualifications. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Romelia Munoz.

On 01/27/2023, from 10:13am to 3:38pm, Licensing Program Analyst (LPA) Rachael De Leon conducted a (24 hour) 10-day complaint visit to the facility above. LPA De Leon met with the Administrator, Jodi Beltrama, and explained the purpose of the visit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20230126152418

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: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
	VISIT DATE: 07/17/2023

NARRATIVE

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The LPA requested the following records for R1 and R2: LIC 602 Physicians Reports, Appraisal Needs and Services Plan (ANS), Hospice Admit records, Hospice Agency Name and phone numbers, Hospice Care Plans, Medication Administration Records (MAR) for 10/2022-11/2022, Centrally Stored Medication and Destruction Records (CSMDR), Incident Reports, Death Reports, Death Certificates, Call pendant logs for 10/2022-11/2022, Staff and Hospice Notes 09/2022-11/2022, Resident Roster for 11/2022 and 01/2023 with telephone numbers, Staff and Hospice notes for 09/2022-11/2022, Staff 1 (S1) hire date at the facility and hire date of last promotion, Staff Roster with telephone numbers for 11/2022 and 01/2023. The LPA informed Administrator that the complaint was referred to the Community Care Licensing (CCL) Investigation Branch (IB). On 03/23/2023 Investigator Munoz contacted the Reporting Party (RP); on 03/24/2023, from approximately 1:00pm to 1:15pm, contacted facility staff to schedule in-person interviews; on 03/27/2023, from approximately 9:30am to 10:10am, conducted interviews with staff; on 04/05/2023, at approximately 2:30pm, with RP; on 04/06/2023, from approximately 4:00pm to 4:05pm, left message for S1 and interviewed Administrator; on 04/11/2023, at approximately 1:40pm, left message for S1; and on 04/14/2023, at approximately 11:39am, interviewed S1. In addition, the investigator reviewed Wilshire Hospice Agency records related to R1 and R2, and facility file documents relevant to the investigation.

The Wilshire Hospice Agency records revealed that on 07/15/2022, R1 was admitted in hospice care and given a life expectancy of six months or less for hypertensive heart with Chronic Kidney Disease. On that same day, R1 was prescribed morphine, .25ml for mild pain, 0.5ml for moderate and 1ml for severe pain to be given every hour or as needed. The death certificate listed the cause of death as Acute Cardiopulmonary Arrest, Congestive Heart Failure, Hypertensive Heart Disease. There were no indications R1’s medications were not given as prescribed.

On 12/30/2021, R2 was admitted in hospice care and given a life expectancy of six months or less if illness runs normal course. On this same day, R2 was prescribed morphine to be taken every hour or as needed for pain. R2 was prescribed .25ml for mild pain, 0.5ml for moderate and 1.ml for severe pain. The death certificate listed the cause of death as Acute Cardiopulmonary Arrest, Congestive Heart Failure, Hypertensive Heart Disease. There were no indications R2’s medications were not given as prescribed.

Continued 9099-C pages

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20230126152418

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: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
	VISIT DATE: 07/17/2023

NARRATIVE

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Information obtained through interviews revealed the hospice nurses individually prepared the syringe with the appropriate dosage of prescribed morphine for R1 and R2. The morphine is usually provided every hour or as needed. The resident is assisted with the self-administration of medication via a syringe provided orally through the resident’s mouth.

Training records reviewed revealed that S1 received “16 hours hand on training before assisting residents with self-administration of medications and 8 hours of instruction completed with a qualified trainer using written materials, discussions, and watching video demonstrations”. This was completed on 10/20/2022 and signed by Corina Segundo, facility Licensed Vocational Nurse (LVN). Based on statements and documentation provided, the allegation is Unsubstantiated at this time.

Exit interview conducted, a copy of this report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20230126152418

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: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
	VISIT DATE: 07/17/2023

NARRATIVE

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On 01/27/2023, from 10:13am to 3:38pm, Licensing Program Analyst (LPA) Rachael De Leon conducted a (24 hour) 10-day complaint visit to the facility above. LPA De Leon met with the Administrator, Jodi Beltrama, and explained the purpose of the visit. The LPA requested the following records for R1 and R2: LIC 602 Physicians Reports, Appraisal Needs and Services Plan (ANS), Hospice Admit records, Hospice Agency Name and phone numbers, Hospice Care Plans, Medication Administration Records (MAR) for 10/2022-11/2022, Centrally Stored Medication and Destruction Records (CSMDR), Incident Reports, Death Reports, Death Certificates, Call pendant logs for 10/2022-11/2022, Staff and Hospice Notes 09/2022-11/2022, Resident Roster for 11/2022 and 01/2023 with telephone numbers, Staff and Hospice notes for 09/2022-11/2022, Staff 1 (S1) hire date at the facility and hire date of last promotion, Staff Roster with telephone numbers for 11/2022 and 01/2023. The LPA informed Administrator that the complaint was referred to the Community Care Licensing (CCL) Investigation Branch (IB).

On 03/23/2023 Investigator Munoz contacted the Reporting Party (RP); on 03/24/2023, from approximately 1:00pm to 1:15pm, contacted facility staff to schedule in-person interviews; on 03/27/2023, from approximately 9:30am to 10:10am, conducted interviews with staff; on 04/05/2023, at approximately 2:30pm, with RP; on 04/06/2023, from approximately 4:00pm to 4:05pm, left message for S1 and interviewed Administrator; on 04/11/2023, at approximately 1:40pm, left message for S1; and on 04/14/2023, at approximately 11:39am, interviewed S1. In addition, the investigator reviewed Wilshire Hospice Agency records related to R1 and R2, and facility file documents relevant to the investigation.

The Wilshire Hospice Agency records revealed that on 07/15/2022, R1 was admitted in hospice care and given a life expectancy of six months or less for hypertensive heart with Chronic Kidney Disease. On that same day, R1 was prescribed morphine, .25ml for mild pain, 0.5ml for moderate and 1ml for severe pain to be given every hour or as needed. On 09/26/2022, R1 showed signs of early transition. Over the span of R1’s care R1’s physical health declined as R1 decreased oral intake. R1’s ambulation capability declined and eventually was lost. R1 sustained multiple falls and a week prior to R1’s death R1 obtained a skin tear from an unknown origin per the facility. R1’s wound was painful, non-healing, and needed to be medicated around the clock. R1 became bedbound, non-verbal and began sleeping majority of the day. R1 spent one day actively dying until R1 passed quickly and comfortably in their room. R1 died on 11/02/2022. The death certificate listed the cause of death as Acute Cardiopulmonary Arrest, Congestive Heart Failure, Hypertensive Heart Disease.
Continued 9099-C pages

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20230126152418

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: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
	VISIT DATE: 07/17/2023

NARRATIVE

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On 12/30/2021, R2 was admitted in hospice care and given a life expectancy of six months or less if illness runs normal course. On this same day, R2 was prescribed morphine to be taken every hour or as needed for pain. R2 was prescribed .25ml for mild pain, 0.5ml for moderate and 1.ml for severe pain. R2 died on 11/23/2022. The death certificate listed the cause of death as Acute Cardiopulmonary Arrest, Congestive Heart Failure, Hypertensive Heart Disease.

Information obtained through interviews revealed the hospice nurses individually prepared the syringe with the appropriate dosage of prescribed morphine for R1 and R2. The morphine is usually provided every hour or as needed. The resident is assisted with the self-administration of medication via a syringe provided orally through the resident’s mouth.

Training records reviewed revealed that S1 received “16 hours hand on training before assisting residents with self-administration of medications and 8 hours of instruction completed with a qualified trainer using written materials, discussions, and watching video demonstrations”. This was completed on 10/20/2022 and signed by Corina Segundo, facility Licensed Vocational Nurse (LVN).

Based on statements and documentation provided, the Department does not have sufficient evidence to determine that R1 and R2, both in hospice care, suffered a questionable death. The death certificate for R1 and R2 stated they died of natural causes. The staff member in question, S1, is certified and trained to assist with medications, including the morphine. The Reporting Party recanted their concerns upon confirmation that R1 and R2 were on hospice care and the Reporting Party does not believe S1 would purposely hurt a resident. Additionally, the hospice providers did not elevate any concerns regarding resident care. Therefore, the allegation Questionable Death is Unfounded at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted, a copy of this report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 6