405802555-4-8-2022-29-AS-KBUY-CDDUUT-20220411155400

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405802555
Report Date: 04/08/2022
Date Signed: 04/08/2022 01:10:32 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
02/02/2022 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20220202105403

FACILITY NAME:	SOUTHLAND HOME		FACILITY NUMBER:	405802555
ADMINISTRATOR:	KATHYRINE VALDEZ		FACILITY TYPE:	740
ADDRESS:	804 SOUTHLAND ST		TELEPHONE:	(805) 929-5096
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	4	CENSUS: 4	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Kathyrine Valdez, Administrator		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Resident sustained a fracture while in care due to staff failing to supervise resident.
Resident's bed rails not in position resulting in resident falling.

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. LPA met with Administrator Kathyrine Valdez and explained the purpose for the visit.

On 02/02/2022, the Department received a complaint regarding an allegation of Neglect/Lack of Care and Supervision. It was alleged that Resident #1 (R1) sustained a fracture while in care due to staff failing to supervise R1 and R1’s bed rails not in position resulting in R1 falling. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Ruben Munoz.

Continued 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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-20220202105403

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: SOUTHLAND HOME	FACILITY NUMBER: 405802555
	VISIT DATE: 04/08/2022

NARRATIVE

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On 02/03/2022, from 12:20pm to 1:15pm, Licensing Program Analyst (LPA) Rachael De Leon conducted the initial complaint visit. LPA De Leon met with Nereida Leal, House Manager and explained the purpose of the visit. LPA toured and took photos of R1’s bedroom. LPA requested documentation pertinent to the investigation. LPA advised the complaint was referred to the Community Care Licensing Investigations Branch (IB) and determined further investigation was needed.

Investigator Munoz conducted interviews with the Reporting Party on 02/09/2022, at approximately 11:30am; with R1’s Representative on 02/11/2022, at approximately 9:02am; with Staff #1 (S1) on 02/14/2022, at approximately 7:48am, with Staff #2 (S2) at approximately 8:36am, with Staff #3 (S3) at approximately 9:12am, with Resident #2 (R2) at approximately 9:40am; with Tri-Counties Regional Center (TCRC) Service Coordinator (SC) on 03/16/2022, at approximately 3:35pm; and with TCRC Quality Assurance Specialist (QAS) on 03/17/2022, at approximately 9:12am. Additionally, Investigator Munoz reviewed Marian Regional Medical Center Medical Records, San Luis Ambulance Medical Records, 911 audio, photos, and facility file documents related to R1.

R1’s facility records revealed R1 was placed at the facility on 10/04/2018. R1’s diagnoses included severe down syndrome, non-verbal, self injurious (SIB) behaviors and osteoporosis. The pre-placement appraisal information listed R1 needs help in transferring in and out of bed, uses wheelchair, and needs special observation and night supervision as R1 sometimes gets out of bed. According to R1’s Individual Service Plan (ISP), R1 uses a wheelchair, uses bilateral arm splints for self injurious behaviors and needs assistance with toileting, eating, bathing, dressing and hygiene.

According to facility staff, on 01/24/2022, at approximately 2:15am, S1 heard R1’s bed alarm signal and found R1 on the floor mat next to bed. 911 records indicate S1 called 911 at 2:31am. Per the ambulance records, R1’s bed was approximately one (1) foot off the ground with a soft mat next to the bed. R1 was transported to the hospital and diagnosed with a left femur fracture. R1 had surgery on 01/24/2022 to repair the left femur fracture.

Continued 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220202105403

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: SOUTHLAND HOME	FACILITY NUMBER: 405802555
	VISIT DATE: 04/08/2022

NARRATIVE

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On 01/26/2022, while still in the hospital, R1’s representative noted swelling on R1’s right upper extremity and wrist deformity. An x-ray of the right forearm was obtained and was consistent with right wrist volar dislocation. On 01/28/2022, a Proximal Row Carpectomy was performed on R1’s right wrist. R1 was discharged back to the facility on 02/09/2022 with a physician’s order for bed rails. A letter of support from the TCRC SC, dated 02/09/2022, was in support of R1 using the bed rails for safety. R1 had not used a bed rail prior to the order on 02/09/2022.

On 02/14/2022, Investigator Munoz took photos of R1’s bed at the facility which showed a half-bed rail, a thick floor pad next to the bed, and a lowered bed. Facility staff denied any neglect or lack of care and supervision. R1’s Representative stated R1 was not neglected and facility staff provide R1 with good care. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegations. Therefore, the above allegations are deemed Unsubstantiated at this time.

Exit interview and copy of report emailed to Administrator/Licensee.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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