405801832-10-29-2024-29-AS-KBUY-DAJV5P-20241030160817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801832
Report Date: 10/29/2024
Date Signed: 10/29/2024 01:24:59 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, 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
02/06/2024 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20240206112415

FACILITY NAME:	WILCOX'S MESA HOME		FACILITY NUMBER:	405801832
ADMINISTRATOR:	BRANDEE CHURCH		FACILITY TYPE:	735
ADDRESS:	711 RIDGE ROAD		TELEPHONE:	(805) 929-3118
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	4	CENSUS: 4	DATE:	10/29/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Back up to Administrator Theresa Becerra		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff neglect resulted in residents being hospitalized while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Back up to Administrator Theresa Becerra and explained the purpose of the visit.

LPA conducted the initial complaint visit on 02/09/2024 conducted interviews, reviewed records, and requested additional records. LPA interviewed staff on 02/09/2024 from 10:15-12:00pm. LPA interviewed additional staff on 10/24/2024 at 4:58pm and on 10/28/2024 at 4:31pm.

On the allegation: Staff neglect resulted in residents being hospitalized while in care. Based on staff interviews the residents at the facility have not been neglected or hospitalized due to neglect. R1 has a pain pump that was set to be replaced in early 2024. On 11/17/2023 R1 had a pre-op for procedure and labs were ordered. R1 has a very hard time doing labs and so far, was not able to get the Labs done. S1 tried again to get R1’s labs completed and tried the regular lab and the hospital but was unable to get the labs done. Continued 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

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 29-AS-20240206112415

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: WILCOX'S MESA HOME	FACILITY NUMBER: 405801832
	VISIT DATE: 10/29/2024

NARRATIVE

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S1 was working with R1’s Doctor, home health and the outpatient surgery center to figure out how they could get labs so the procedure could be performed. On 12/18/2024 R1 was taken to R1’s Primary Doctor regarding some hip pain and an annual visit to discuss labs, Tylenol was prescribed for hip pain and it was unrelated to the pain pump. On 12/21/2024 R1 had another appointment with pain management to refill the pain pump. The Administrator was discussing with R1’s doctor if labs could not be done if they could go to pill form of the medication and not replace the pump. On 01/28/2024 R1 was having pain issues and was sent to the ER was discharged will follow up with Pain Management appointment set for 02/07/2024. On 02/01/2024 R1 was taken to Surgery center to have R1’s procedure done, R1 was having a high heart rate and was referred to go the ER, tests were run and R1 was admitted for observation, tests came back negative, and everything looked good. On 02/15/2024 R1 was taken to appointment at the Surgery Center to have the pain pump procedure but had a high temperature and was told to go to the ER, R1 was diagnosis with Rhinovirus, given antibiotics, was admitted to the hospital and had some fluid drained around the pump. On 04/18/2024 R1 was taken to the ER, R1 was admitted for tests which revealed a UTI diagnosis and R! was discharged on 04/202024. R1 did have the surgery in May 2024 to replace the battery on the pain pump. Staff acted when R1 was not feeling well, taken to the ER when needed and was hospitalized on 2 occasions. Based on the evidence staff did not neglect R1 and therefore this allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report printed for back up to Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC9099 (FAS) - (06/04)

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