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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850174
Report Date: 03/23/2023
Date Signed: 03/23/2023 10:53:46 AM

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
08/26/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20220826083247
FACILITY NAME:GARDEN HOUSE MORRO BAYFACILITY NUMBER:
405850174
ADMINISTRATOR:BRETT K. ALLANFACILITY TYPE:
740
ADDRESS:480 MAIN STTELEPHONE:
(805) 709-2242
CITY:MORRO BAYSTATE: CAZIP CODE:
93442
CAPACITY:15CENSUS: 14DATE:
03/23/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rebecca MichelTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not seek timely medical care for resident.
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. During today’s visit, LPA De Leon met with Co-Administratror Rebecca Michel and explained the purpose for the visit.

On 8/26/2022, the Department received a complaint for this facility. It was alleged that Resident #1 (R1) sustained an unwitnessed fall that resulted in a fracture and staff failed to seek timely medical care for R1 after R1 was found on the dining room floor. The complaint was referred to Community Care Licensing Investigations Branch (IB) to obtain R1’s medical records and to confirm that dates of the fall and when medical attention was received.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
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 7
Control Number 29-AS-20220826083247
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 HOUSE MORRO BAY
FACILITY NUMBER: 405850174
VISIT DATE: 03/23/2023
NARRATIVE
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On 08/29/2022, between 2:27pm and 3:45pm, Licensing Program Analyst (LPA) Rachael De Leon conducted a 10-day complaint visit to the facility. LPA De Leon met with Rebecca Michel, Co- Administrator and explained the purpose of the visit. The LPA requested documents pertinent to the investigation and took photos of the dining room area. The LPA determined further investigation was needed and would return on a later date to issue the final findings.

LPA De Leon conducted interviews on 08/29/2022, from 11:23am to 2:30pm, with the Co-Administrator and R1’s resident representative. In addition, the IB Special Investigator Assistant (SIA) obtained and reviewed copies of French Hospital Medical Center medical records for R1. The facility file documents related to R1 were also reviewed.

A review of the Special Incident Report (SIR) and the Co-Administrator’s written timeline of the incident revealed R1 was ambulatory without assistance and enjoyed walking freely around the facility. On 07/02/2022 after dinner, R1 continued to stay seated in the chair at the dining room table and dozed off. R1 fell out of the chair. Staff did not see R1 fall but saw R1 on the floor. Staff attempted to help R1 up and discovered R1 was in pain and not able to stand. Between 7:00 and 7:30pm, staff phoned the Co-Administrator, who was unavailable to come to the facility, but was able to FaceTime with the staff and observe R1 who appeared alert, eyes open and normal self. At approximately 7:45pm, the Co-Administrator phoned R1’s resident representative, who arrived at the facility shortly after and assisted the staff to get R1 off the floor, into the recliner to change, and assisted to bed. R1 was crying out in pain. At 9:00pm, R1’s representative texted the Co-Administrator to inform them that R1 was in bed sleeping and that R1’s left thigh area was swollen. The decision was made to wait until the morning to call 911 to see if R1’s condition was not improved or worsened. On 07/03/2022, at 7:30am, the Co-Administrator and R1’s resident representative observed R1’s hip area was very swollen. 911 was called and paramedics took R1 to French Hospital Medical Center.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20220826083247
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 HOUSE MORRO BAY
FACILITY NUMBER: 405850174
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2023
Section Cited
CCR
87465(a)(1)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
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Licensee will submit plan how you will ensure residents receive timely medical care. Submit to CCL by 03/24/2023
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Based on record review and interviews, the licensee did not comply with the section cited above. Staff did not obtain timely medical attention for R1 when R1 was discovered on the floor, complained of pain, unable to stand on own and had a swollen thigh which was later diagnosed as a fractured left hip, which posed an immediate health and safety risk to residents in care.
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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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
08/26/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20220826083247

FACILITY NAME:GARDEN HOUSE MORRO BAYFACILITY NUMBER:
405850174
ADMINISTRATOR:BRETT K. ALLANFACILITY TYPE:
740
ADDRESS:480 MAIN STTELEPHONE:
(805) 709-2242
CITY:MORRO BAYSTATE: CAZIP CODE:
93442
CAPACITY:15CENSUS: 14DATE:
03/23/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rebecca Michel Co-AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Due to neglect, resident sustained a fracture while in care.
Staff did not report resident's fall to Community Care Licensing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA De Leon met with Rebecca Michel Co-Administrator and explained the purpose for the visit.

On 08/26/2022, the Department received a complaint regarding allegations of “Due to neglect, resident sustained a fracture while in care” and “Staff did not report resident's fall to Community Care Licensing”. The reporting party alleged that Resident 1 (R1) fell and sustained a fracture as a result of facility negligence, and did not report the fall to Community Care Licensing (CCL).
Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20220826083247
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 HOUSE MORRO BAY
FACILITY NUMBER: 405850174
VISIT DATE: 03/23/2023
NARRATIVE
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The complaint was referred to Community Care Licensing Investigations Branch (IB) to obtain R1’s medical records and to confirm that dates of the fall and when medical attention was received.

On 08/29/2022, between 2:27pm and 3:45pm, Licensing Program Analyst (LPA) Rachael De Leon conducted a 10-day complaint visit to the facility. LPA De Leon met with Rebecca Michel, Co- Administrator and explained the purpose of the visit. The LPA requested documents pertinent to the investigation and took photos of the dining room area. The LPA determined further investigation was needed and would return on a later date to issue the final findings.

LPA De Leon conducted interviews on 08/29/2022, from 11:23am to 2:30pm, with the Co-Administrator and R1’s resident representative. In addition, the IB Special Investigator Assistant (SIA) obtained and reviewed copies of French Hospital Medical Center medical records for R1. The facility file documents related to R1 were also reviewed.

On the allegation: Due to neglect, resident sustained a fracture while in care. A review of the Special Incident Report (SIR) and the Co-Administrator’s written timeline of the incident revealed R1 was ambulatory without assistance and enjoyed walking freely around the facility. On 07/02/2022 after dinner, R1 continued to stay seated in the chair at the dining room table and dozed off. R1 fell out of the chair. Staff did not see R1 fall but saw R1 on the floor. Staff attempted to help R1 up and discovered R1 was in pain and not able to stand. Between 7:00 and 7:30pm, staff phoned the Co-Administrator, who was unavailable to come to the facility, but was able to FaceTime with the staff and observe R1 who appeared alert, eyes open and normal self. At approximately 7:45pm, the Co-Administrator phoned R1’s resident representative, who arrived at the facility shortly after and assisted the staff to get R1 off the floor, into the recliner to change, and assisted to bed. R1 was crying out in pain. At 9:00pm, R1’s representative texted the Co-Administrator to inform them that R1 was in bed sleeping and that R1’s left thigh area was swollen. The decision was made to wait until the morning to call 911 to see if R1’s condition was not improved or worsened. On 07/03/2022, at 7:30am, the Co-Administrator and R1’s resident representative observed R1’s hip area was very swollen. 911 was called and paramedics took R1 to French Hospital Medical Center.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20220826083247
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 HOUSE MORRO BAY
FACILITY NUMBER: 405850174
VISIT DATE: 03/23/2023
NARRATIVE
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A review of R1’s hospital medical records, revealed R1 was taken to the hospital by ambulance and admitted to French Hospital Medical Center on 07/03/2022 and diagnosed with a Left Intertrochanteric Hip Fracture. The records state R1 had a mechanical fall the day before where they fell backwards.

Staff observed R1 seated at the dining table after dinner, R1 dozed off, and then sustained an unwitnessed fall resulting in the fracture.

Based on the information obtained, the allegation “Due to neglect, resident sustained a fracture while in care” is deemed Unsubstantiated at this time.

On the allegation: Staff did not report resident's fall to Community Care Licensing. The LPA reviewed a copy of the Special Incident Report (SIR) for R1’s fall on 07/02/2022 which resulted in a fractured left hip. The SIR is signed and dated 07/07/2022 and was faxed to CCL on the same date. The SIR lists an incorrect date the fall occurred as 07/03/2022. During today’s visit, the Administrator was advised to submit a corrected SIR with the correct date occurred as 07/02/2022.

Based on the information obtained, the allegation “Staff did not report resident's fall to Community Care Licensing” is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20220826083247
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 HOUSE MORRO BAY
FACILITY NUMBER: 405850174
VISIT DATE: 03/23/2023
NARRATIVE
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A review of R1’s hospital medical records, revealed R1 was taken to the hospital by ambulance and admitted to French Hospital Medical Center on 07/03/2022 and diagnosed with a Left Intertrochanteric Hip Fracture. The nursing assessment note at 9:18am states patient fell last night at memory care facility. The history of present illness notation explains R1 was “brought in by ambulance from their long-term care facility after a fall yesterday.” It goes on to state that R1 had a mechanical fall the day before where they fell backwards. R1’s resident representative was called and immediately went to visit R1. “R1 seemed to be OK, so they put R1 back in bed.” R1 did complain of some left hip pain from what they could tell and there was some swelling, but they decided to wait it out overnight as R1 appeared comfortable once in bed. The next morning R1 has continued to complain of pain and is unable to bear any weight. Ambulance was then contacted.

The facility “Fall Prevention Practice at Garden House” was reviewed and indicated to call 911 when there is: profuse bleeding; blow to head; resident can verbalize they are in pain; can’t walk. After R1 fell on 07/02/2022, R1 verbalized they were in pain and could not stand up by self.

R1’s immediate complaint of pain, inability to stand up by self and visible swollen thigh area on 07/02/2022 should have prompted the facility to seek timely medical attention which they did not. 911 was not called until the next morning on 07/03/2022. R1 was admitted to the hospital and diagnosed with a left hip fracture.

Based on the information obtained, the allegation “Staff did not seek timely medical care for resident” is deemed Substantiated at this time.
Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)

Exit interview conducted, deficiency cited, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7