405850174-8-16-2023-29-AS-RDLN-CURNAS-20230816101800

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850174
Report Date: 08/16/2023
Date Signed: 08/16/2023 10:19:49 AM

Document Has Been Signed on 08/16/2023 10:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	REBECCA A. MICHEL		FACILITY TYPE:	740
ADDRESS:	480 MAIN ST		TELEPHONE:	(805) 772-7181
CITY:	MORRO BAY	STATE: CA	ZIP CODE:	93442
CAPACITY: 15	TOTAL ENROLLED CHILDREN: 0	CENSUS: 15	DATE:	08/16/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rebecca Michel, Administrator		TIME COMPLETED:	10:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) De Leon conducted a Case Management- deficiency visit to the facility above. LPA met with Administrator, Rebecca Michel and explained the purpose of the visit. LPA De Leon reviewed an incident report sent to Community Care Licensing (CCL) by the facility above. The incident report dated 07/26/2023 was regarding Resident 1 (R1) reporting at 8:00 pm R1 had a large new bump on left ankle, Staff 1 (S1) called Administrator and sent a picture. Hospice was contacted and facility was instructed to ice and elevate, and Hospice would be out in the morning to check on R1. At 12:30 am S1 noticed the bump had tripled in size sent another picture and called Administrator. Hospice was contacted again, and Hospice staff left VM with the Hospice on call doctor. The Hospice Nurse arrived at the facility at 2:05 am checked on R1’s leg and attempted to call the Hospice on-call doctor again leaving another message. Hospice Nurse administered medications to R1 for R1’s discomfort. S1 checked on R1 again at 3:30 am and 5:00 am noting R1 was sleeping. Hospice Nurse called the facility at 5:00 am stating the Hospice on-call doctor directed R1 to be taken by ambulance to the hospital. Administrator arrived at the facility at 6:00 am and at 6:15 am the bump on R1’s leg had opened, R1’s leg was wrapped several times to stop the bleeding. Paramedics arrived at 6:45 am and R1 was taken to French Hospital ER and was later discharged back to the facility around 11:00 am. LPA De Leon requested copies of R1’s Hospice Care Plan, R1’s hospital discharge paperwork and the photos that had been taken of R1’s leg/ankle. LPA De Leon received all the documents requested and reviewed all documentation sent. Continued 809-C

Kelly Burley	TELEPHONE: (805) 562-0413
Rachael De Leon	TELEPHONE: (805) 450-0262
	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/16/2023

NARRATIVE

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The Hospice care plan dated 07/19/2023 for R1 does not mention a bump or a wound in the care plan.
The Hospice nurse visit notes dated 07/26/2023 at 2:05 am stated R1 assessed for LE Wound, fluid filled blister, wound 26 cm (10 inch) X 12 cm (5 in), tender, medications issued for comfort, R1 able to answer simple questions, LE elevated on pillow, calls out in pain, collaborated with facility staff, wound left OTA at this time, wound supply dressing left in case blister opened, planned for further follow-up, attempted to reach Hospice on call doctor, VM left, supervisor on call made aware of situation and at 2:30 am wound outlined for reference.

The Hospice Chart/Clinical Notes reporting period 07/26/2023 through 07/28/2023 stated RN assessed wound, LLE elevated on pillow, Instruction not to apply heavy blankets or ice packs to site, site left OTA at this time, dressing for wound left in case wound spontaneously opened, R1 cooperative with care but randomly called out, RN Administered medications for optimal comfort, Follow up scheduled for later this am with collaboration required with MD to determine POC, site with extreme edema and fluid that may need lancing, VMx2 left with Hospice Doctor and supervisor informed. Direct call received from Hospice on call doctor who is wanting R1 transported right away to ED to have wound evaluated and drained with option for pain control measures prior to care.

French Hospital Discharge instructions were reviewed R1 had a visit date of 07/26/2023 with reason for visit being skin lesion bleed with a discharge diagnosis of a Hematoma.

The Hospice care plan was updated as of 08/01/2023 for R1 and now mentions Wound/Skin in the care plan.

Based on the record reviewed this was a new wound for R1 and was not part of R1’s Hospice Care Plan prior to 08/01/2023 therefore the facility should have provided timely medical attention for R1.

Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/21/2025 08:36 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/21/2025 08:26 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 08/17/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	...residents regularly observed for changes in physical,... and that appropriate assistance is provided...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to reevaluate facilities policy and procedures for timely medical attention, when to call 911, when to call hospice then train staff on all policies and procedures as well as regulations 87465 and 87469, provide an up-to-date LIC 500, with staff training records and all staff signatures to CCL.
	8 9 10 11 12 13 14	Based on record review and photographs the licensee did not comply with the regulation above R1 sustained a bump/wound called hospice instead of seeking timely medical attention for R1 which poses an immediate health, safety, and personal rights risks to resident in care.	8 9 10 11 12 13 14	This page has been amended and regulation changed to 87466
	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.

Kelly Burley	TELEPHONE: (805) 562-0413
Rachael De Leon	TELEPHONE: (805) 450-0262
	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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