405802280-1-26-2024-29-AS-KBUY-D2WNNS-20240229093714

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405802280
Report Date: 01/26/2024
Date Signed: 01/26/2024 10:25:13 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
03/03/2023 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20230303132847

FACILITY NAME:	C.A.L.L. - VALDEZ HOUSE		FACILITY NUMBER:	405802280
ADMINISTRATOR:	KYLAN REYNOSO		FACILITY TYPE:	740
ADDRESS:	4305 VALDEZ AVE		TELEPHONE:	(805) 460-6663
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	4	CENSUS: 4	DATE:	01/26/2024
		UNANNOUNCED	TIME BEGAN:	08:27 AM
MET WITH:	Administrator - Kyland Reynoso		TIME COMPLETED:	11:28 AM

ALLEGATION(S):

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Facility staff did not seek medical attention in a timely manner for resident in care.

INVESTIGATION FINDINGS:

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At 8:30am on 01/26/2024, Licensing Program Analyst (LAP) Jeffries arrived unannounced at the facility to issue final findings to this complaint. LPA met with Administrator, Kyland Reynoso announced who he is and the reason for the visit. LPA issued final findings on a separate complaint for this facility on this same visit.

As to the allegation of, “Facility staff did not seek medical attention in a timely manner for resident in care.” It was alleged that on 02/09/2023 Resident 1 (R1) was not provided timely medical attention. It was discovered through interviews and documentation that on 08/31/2023, R1 had a routine medical appointment with Dr. Bower, who ordered UTI test, where R1 left urine sample and follow-up scheduled medical appointment on 09/15/2023. On 09/16/2022, R1 had a comprehensive physical assessment (LIC602) completed by Hanah Rower, N.P. where R1 was documented to have a chronic bladder impairment (urine incontinent). On 12/19/2022, CONTINUED on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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-20230303132847

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. - VALDEZ HOUSE	FACILITY NUMBER: 405802280
	VISIT DATE: 01/26/2024

NARRATIVE

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R1 had a surgery procedure of Prostate Transurethral Vaporization and returned to the facility with orders to proceed as normal, on 12/21/2022 R1 had surgery follow up visit, no issues reported. On 01/22/2023 R1 had a mobile dental hygiene visit. On 01/31/2023, R1 had an appointment with Urologist Dr. Perkins, who documented, “symptoms of decline” related to R1’s surgery on 12/19/2023. Interviews on 03/06/2023 of Staff 1 and 3 (S1, S3) indicated that R1 had maintained a baseline upon returning from surgery in January and never improved and declined gradually, despite being on antibiotics. S3 stated that R1 gradually declined and was taken to the Emergency Room (ER) on 02/09/2023 where R1 was diagnosed with a bladder urinary tract infection (UTI) then cleared by the ER to return to the facility. On 02/18/2023, S3 noticed increasing symptoms and took R1 to the ER, where R1 was admitted to the Hospital for observations. On 03/19/2023, R1 was placed on Hospice Care through Central Coast Hospice. On 03/31/2023, R1 succumbed to their illness and passed away on 03/31/2023. Additionally, facility documentation included daily temperature checks, medication checks, and sunscreen checks from January 2021 through February of 2023 excluding days spent in hospitalization. LPA noted that the decline in R1 due to of complications from the bladder infection based on documentation, medical assessments and staff interviews indicated a gradual decline in R1’s baseline ADL’s. Documentation, medical appointments, and Emergency Room visits show evidence of staff seeking medical attention in a timely manner due to the nature of the decline of R1. Additionally, LPA Jeffries contacted Tri Counties Regional Center and no significant findings in R1’s care at this facility from TCRC. . At this time there is not enough evidence to support the allegation of, “Facility staff did not seek medical attention in a timely manner for resident in care.” and is unsubstantiated at this time.

Exit interview, report read, and report provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

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