405850222-9-1-2023-29-AS-KBUY-CX5KLA-20231031075936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850222
Report Date: 09/01/2023
Date Signed: 09/01/2023 02:35:57 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
08/23/2023 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20230823161237

FACILITY NAME:	LIFETOUCH THE ELEGANT LIVING RESIDENTIAL HOME CARE		FACILITY NUMBER:	405850222
ADMINISTRATOR:	AQUINO, AMELITA I.		FACILITY TYPE:	740
ADDRESS:	1934 TULIPWOOD DRIVE		TELEPHONE:	(805) 878-3409
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	6	CENSUS: 5	DATE:	09/01/2023
		UNANNOUNCED	TIME BEGAN:	11:09 AM
MET WITH:	Dennis Paguio / Care Giver		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Due to a lack of supervision, a resident wandered into another resident's room

INVESTIGATION FINDINGS:

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At 11:00am on 09/01/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility to deliver final findings to the allegation above to this complaint. LPA announced who he was and the reason for the visit. LPA met with Staff 1 (S1). S1 contacted Administrator Amelita Aquino by phone, LPA received permission from Administrator to issue final findings to S1.
As to the allegation of, “Due to a lack of supervision, a resident wandered into another resident's room it was discovered through interviews, documentation and admission that on 8/21/2023 at approximately 2:15am Resident 1 (R1) entered R2’s room, R1 then placed hand on R2 resulting in Emergency Room evaluation for both R1 and R2. The Facilities Physicians Report (LIC602) indicate that both R1 and R2 have diagnosis that require facility to have awake staff with line of sight of residents during the overnight shifts [CCLD Regulation 87705(4)(A)]. Facility Personnel Report (LIC500) and staff schedules provided show no documented staff coverage for the date of 08/21 through 08/22 for the overnight shift. LIC500 indicated that S1 was scheduled to start work at 6am on 08/21/2022 and scheduled to be off at 1pm on 08/21/2023.

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: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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-20230823161237

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: LIFETOUCH THE ELEGANT LIVING RESIDENTIAL HOME CARE	FACILITY NUMBER: 405850222
	VISIT DATE: 09/01/2023

NARRATIVE

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Interviews on 08/27/2023 with Staff 1 (S1) revealed that S1 started work at 6am on 08/21/2023 and continued to work for more than 20 hours from the start of S1’s shift to the time of the incident with R1 and R2. S1 stated that no other staff was schedule to work the overnight shift from 08/21 through 08/22. S1 stated that they fell asleep sometime during the night shift and awoke when S1 heard R1 shuffling their feet walking from R1’s room to the bathroom. S1 then got up to drink water when S1 then heard R2 scream. S1 then went to R2 room and separated R1 from R2. Due to the facility not scheduling staff, failing to maintain line of sight of resident of R1, who was known to wonder into other residents rooms, excessive continual working hours of S1, failing to provide staff reasonable staff relief, and falling asleep during the overnight shift, there is enough evidence to support the allegation of, “Due to lack of supervision, a resident wondered into another resident’s room.” And is substantiated at this time.

Exit interview, report read, 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: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230823161237

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: LIFETOUCH THE ELEGANT LIVING RESIDENTIAL HOME CARE	FACILITY NUMBER: 405850222
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/04/2023 Section Cited CCR 87705(c)(4)(A)	1 2 3 4 5 6 7	87705 (c)(4)(A) (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s	1 2 3 4 5 6 7	Administrator is to immediately start the process of hiring new staff until there is suffocate staff to cover all shifts at this facility with its current staffing needs.
	8 9 10 11 12 13 14	physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement was not met by evidence of staff not being scheduled for overnight shift and staff sleeping, which poses an immediate risk for 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: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

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