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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801985
Report Date: 05/19/2022
Date Signed: 05/20/2022 10:38:48 AM

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
11/09/2020 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20201109093650
FACILITY NAME:PASO SENIOR CAREFACILITY NUMBER:
405801985
ADMINISTRATOR:MEYNARD MARCOSFACILITY TYPE:
740
ADDRESS:197 CARDINAL WAYTELEPHONE:
(805) 835-4762
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 5DATE:
05/19/2022
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Maynard Marcos/LicenseeTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Resident sustained unexplained injury while in care.

Staff did not report changes in resident's condition to responsible parties.

Staff did not seek timely medical attention for resident.
INVESTIGATION FINDINGS:
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 At 8:30am on 05/19/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility and conducted a subsequent complaint visit to the above facility to deliver final findings. LPA met with Maynard Marcos (via telephone, as he was COVID positive at his personal residence) and explained the purpose of the visit.

LPA Jeffries started the investigation on 11/13/2020 at 12:40pm, and interviewed licensee Maynard Marcos over the phone and requested relevant documents. On 4/27/2022, LPA Olson conducted interviews via telephone with Licensee Meynard Marcos at 4:30pm and Resident 1 (R1)’s POA at 4pm. On 4/28/22 at 1:15pm LPA Olson interviewed Staff (S1) in person at the facility. On 5/18/2022 at 3:30pm, LPA interviewed R1’s physician’s physician assistant, who spoke with R1’s physician about the case. On 5/13/22 and 5/17/20 LPA Olson reviewed Hospice notes and visit summaries.

CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
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-20201109093650
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: PASO SENIOR CARE
FACILITY NUMBER: 405801985
VISIT DATE: 05/19/2022
NARRATIVE
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On the allegation: Resident sustained unexplained injury while in care. The licensee stated R1’s hospice nurse visited on 11/4/2020 and stated that R1 was in good condition. The next day, 11/5/2020, R1 was more tired than usual and did not respond to questions. The licensee and staff stated at the time, they thought R1 was just have a “bad day.” Licensee Maynard Marcos stated R1 “does this at times,” where R1 “will sleep all day and then wake up the next day and be back to normal it was not out of the ordinary.” The next day, 11/6/2020, when R1 still presented as very tired and less responsive, staff notified hospice of R1’s decline. According to hospice records, hospice was called at 3pm on 11/6/2020 to note R1’s change of condition and decline. Hospice arrived at 3:45pm and observed R1. Hospice Nurse, licensee, and staff were present during the visit. Hospice nurse observed redness/bruising on R1’s left hip. Licensee and staff stated R1 did not sustain an injury or fall around the time the redness/bruise appeared. Licensee thought the redness/bruising could be due to R1 preferring to lay on their left side, and the lack of muscle and fat rubbing against the bone caused redness. Licensee and staff stated R1 had no other injuries or bruises at the time, and the licensee stated that supports that R1 did not sustain a fall around this time. Hospice notes from 11/6/2020 at 3:45pm state, “Left hip with 9x6 cm area of pink and purplish discoloration, with small amount swelling around the discolored area.” Hospice nurse conducted a televisit with R1’s physician to assess the redness on R1’s hip. R1’s physician suggested ordering an x-ray of the hip to determine if there was any injury, but R1’s POA declined the x-ray and decided to pursue comfort care instead. R1’s physician’s physician assistant (PA) discussed the case with R1’s physician. PA stated in an interview according to the physician, it was possible for older residents to have weakened blood vessels that break and then pool at a section that is a dependent part, like the hip the resident is laying on, and the redness/bruising may or may not have been due to an injury. When R1’s POA was interviewed on 4/27/2022, 17 months after the incident, they stated they thought R1 slipped out of bed around the time of the redness/bruise, but did not remember a large bruise or injury. R1’s POA was satisfied with the care and supervision R1 received at the facility. Based on the information obtained, there is not sufficient evidence to support the allegation at this time. Therefore the allegation is deemed Unsubstantiated at this time.

CONTINUED on LIC9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20201109093650
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: PASO SENIOR CARE
FACILITY NUMBER: 405801985
VISIT DATE: 05/19/2022
NARRATIVE
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On the allegation: Staff did not report changes in resident’s condition to responsible parties. R1’s POA stated the facility always informed the POA promptly on Resident 1’s condition. R1’s POA had no concerns about notification regarding R1’s condition. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff did not seek timely medical attention for resident. On 11/5/2020, licensee and staff noticed R1 was more tired than usual and was less responsive than usual. The licensee and staff stated at the time, they thought R1 was just have a “bad day.” Licensee Maynard Marcos stated R1 “does this at times,” where R1 “will sleep all day and then wake up the next day and be back to normal it was not out of the ordinary.” The next day, 11/6/2020, when R1 still presented as very tired and less responsive, staff notified hospice of R1’s decline. A hospice nurse visited R1 on 11/6/2020, and R1’s physician had a televisit with R1 on 11/6/2020. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview, report signed and copy provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3