405850002-4-14-2022-29-AS-KBUY-CDLNN4-20220418103607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850002
Report Date: 04/14/2022
Date Signed: 04/14/2022 04:45:05 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
01/14/2021 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20210114091037

FACILITY NAME:	YELLOW ROSE ASSISTED LIVING		FACILITY NUMBER:	405850002
ADMINISTRATOR:	TESFAZGY, ABIY		FACILITY TYPE:	740
ADDRESS:	4225 CAMP 8 RD		TELEPHONE:	(805) 286-8477
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	15	CENSUS: 12	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Abiy Tesfazgy, Administrator		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Resident left in soiled diaper for extended period of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint investigation to the facility above to issue final findings. LPA met with Abiy Tesfazgy, Administrator, and explained the purpose of the visit. LPA Jeffries started the investigation on 1/21/2021 and met with the administrator telephonically. Resident 1 (R1)’s Responsible Party and Power of Attorney (POA) was interviewed on 1/21/2021 at 10:30am. LPA Olson conducted additional staff and resident interviews on 4/14/2022.

The complainant’s concern was that on 1/13/2021, R1 went to the hospital at 10:40pm and was observed to have a soiled brief and a UTI. The administrator confirmed R1 went to the hospital on the night of 1/13/2021 for a UTI. The facility is located in a rural area and internet maps showed the hospital is 16 miles or about 22 minutes away from the facility.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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-20210114091037

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: YELLOW ROSE ASSISTED LIVING	FACILITY NUMBER: 405850002
	VISIT DATE: 04/14/2022

NARRATIVE

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The administrator also stated staff changed R1’s brief on the bed before R1 went to the hospital and put two briefs on R1 and put a chuck pad under R1 for extra protection. The administrator and staff confirmed they do not normally put two briefs on a resident, but have when the resident is being sent to the hospital since they are not sure how long the resident will be there. Administrator stated they don't want residents to be uncomfortable so do all they can to unsure residents are changed before leaving the facility. Administrator stated it took 20 minutes for the ambulance to leave, when the ambulance got to Twin Cities Hospital there were no beds and R1 was left in the Ambulance for 30-45 minutes before one was available. The hospital nurse only noted the briefs were soiled, but did not note double diapering. Staff interviews and documentation confirmed they check residents requiring incontinence care every 2 hours, as well as before and after each meal. Residents interviewed stated their needs were met and they did not have any concerns.

An interview with R1’s POA revealed the POA was R1’s primary caregiver for years prior to R1 living in this facility. The POA stated R1 does not like anyone to change R1 and R1 would prefer to stay in a soiled garment rather than tell a caregiver they are soiled, due to the emotional aversion of someone changing R1. The POA stated they have no issues or concerns with the care the facility provides and feels the staff do a “great job” taking care of R1. The POA stated they saw R1 through a window visit at the facility on 1/13/2021 and on 1/14/2021. The POA stated R1 was changed during both visits and that the staff did a good job changing R1 in light of the higher changing needs of R1.

Based on the information obtained, the allegation is deemed unsubstantiated at this time. Exit interview, report emailed. A Technical Assistance Advisory Note was issued to advise administrator not to put two briefs onto residents.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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