405802287-10-26-2023-29-AS-KBUY-CX5KQ6-20231031080549

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405802287
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:05:26 PM

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
08/31/2022 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20220831083830

FACILITY NAME:	GARDEN VIEW INN		FACILITY NUMBER:	405802287
ADMINISTRATOR:	KOC DE JONG, DIMFNA		FACILITY TYPE:	740
ADDRESS:	7105 SAN GABRIEL RD		TELEPHONE:	(805) 462-2273
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	15	CENSUS:	DATE:	10/26/2023
		UNANNOUNCED	TIME BEGAN:	10:47 AM
MET WITH:			TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff dropped resident resulting in bruising.

INVESTIGATION FINDINGS:

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As to the allegation of, “Staff dropped resident resulting in bruising“ On 08/29/2022 at approximately 6:15pm, Staff 3 (S3) attempted to assist Resident 1 (R1) with an incontinent issue. While using a Sit To Stand Lift, R1 was reported to have an assisted fall to the floor with S3 assisting with towel, according to incident report dated 08/30/2023, which resulted in bruising on the left wrist of R1. On 08/30/2022, R1 stated to a reliable witness that R1 had a fall because “staff had dropped” R1. On 09/01/2022, Licensing Program Analyst (LPA) Jeffries interviewed R1, R1 was not capable of being verbal at that time, however when LPA told R1 that he was there about a fall and asked R1, “did you have any bruising” R1 pulled their arm out from a blanket and showed LPA the bruising on R1’s left arm. LPA was given permission to take photographs of the bruising. Interview with S1 on 09/01/2022 stated that the Licensee provided training on the Sit To Stand Lift that was used during this fall in question, but did not remember the date or other staff that were also trained on the Sit To Stand Lift. On 10/26/2023, LPA interviewed S3 who was

CONTINUED on LIC9099-C

Substantiated

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: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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-20220831083830

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: GARDEN VIEW INN	FACILITY NUMBER: 405802287
	VISIT DATE: 10/26/2023

NARRATIVE

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the staff that assisted R1’s fall on 08/29/2023 according to the incident report and interview, S3 was able to recall the fall on 08/29/2023 in detail and stated that, “I’ve had training on Hoyer and Sara lift prior to working at this facility.” LPA asked S3 if they had ever been trained on the Sit To Stand Lift, S3 stated, “no”. On the initial investigation visit, LPA requested in writing that Licensee provide, Staff training records for any resident lift requirements (will need to request training records with Licensee at a later time) LPA also called Licensee on 09/01/2023 and made verbal request for those documents.
On 09/02/2022, Licensee provided a training log for Hoyer lift, stating those trained were, “(Licensee) and a few … staff”, training did not specify which staff. On 10/25/2023, Licensee provide physicians script stating that “(facility) staff had been trained on sit to stand lift” on January 20, 25, and 27. But did not specify which staff. On 09/08/2022. Licensee provided a doctor’s order dated 09/02/2023, for R1 stating, “after prior verbal consent, staff may use Sara Lift when patient (R1) is not cooperating with sit to stand lift …” LPA noted that there was no lift orders or documentation that the physician issued a “verbal order” to use any assisted lift devices with R1 prior to the fall on 08/29/2023. Additionally, the staff that was attending to R1 during the fall on 08/29/2023 stated they had not had any assisted lift device training at this facility. The fall on 08/29/2022 resulted in bruising on R1’s left arm, while using the Sit To Stand Lift with staff that was not trained by admission and no documentation of training. Based on lack of documentation to support proper staff training, admission of no training on Sit To Sand Lift device, and staff to use assisted lift devices with R1 at the time of the fall that resulted in bruising, there is enough evidence to support the allegation of, “Staff dropped resident resulting in bruising” and is substantiated at this time.

Exit interview, citation issued, appeal rights 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: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220831083830

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: GARDEN VIEW INN	FACILITY NUMBER: 405802287
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/09/2023 Section Cited CCR 87606(f)(3)	1 2 3 4 5 6 7	87606 Care of Bedridden Residents (f) To accept or retain a bedridden person, a facility shall ensure the following:(3)Staff records include documentation of staff training specific to Care of Bedridden Residents. This requirement was not met by evidence of admission and no	1 2 3 4 5 6 7	Licensee plans to review all training records and update records to comply with regulations standards, Licensee will update LPA by phone or email by 11/09/2023.
	8 9 10 11 12 13 14	documentation of training on Sit To Stand Lift while assisting resident who fell, Which poses potential danger to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC9099 (FAS) - (06/04)

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