405850249-6-8-2023-29-AS-KBUY-CT7Q7H-20230627115510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850249
Report Date: 06/08/2023
Date Signed: 06/08/2023 11:50:32 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
03/02/2023 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20230302100956

FACILITY NAME:	INGLESIDE ASSISTED LIVING		FACILITY NUMBER:	405850249
ADMINISTRATOR:	DAUGHERTY, NIKOLE		FACILITY TYPE:	740
ADDRESS:	10630 WEST FRONT ROAD		TELEPHONE:	(805) 460-6541
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	16	CENSUS: 15	DATE:	06/08/2023
		UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Brett Allan, Licensee, and Nikole Daugherty, Administrator		TIME COMPLETED:	12:05 PM

ALLEGATION(S):

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Due to lack of staff intervention, an altercation between residents resulted in injuries.

INVESTIGATION FINDINGS:

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On 6/8/23 at 11:01 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced subsequent complaint visit to the deliver findings for the above allegation. LPA met with Brett Allan, Licensee, and Nikole Daugherty, Administrator, and explained the reason for the visit.

On 03/02/2023, the Department received a complaint alleging “Due to lack of staff intervention, an altercation between residents resulted in injuries.” It was alleged that facility Staff #1 (S1) failed to intervene when Resident #1 (R1) and Resident #2 (R2) had a physical altercation which resulted in R1 sustaining injuries. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Elisia Rippe.

Continued on 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

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-20230302100956

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: INGLESIDE ASSISTED LIVING	FACILITY NUMBER: 405850249
	VISIT DATE: 06/08/2023

NARRATIVE

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On 03/02/2023, from 1:00pm to 2:15pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced 24-hour initial complaint visit. LPA met with Brett Allan, Licensee, and Nikole Daugherty, Administrator, and explained the purpose of the visit. The LPA interviewed the Licensee and Administrator and obtained copies of documents and surveillance video pertinent to the investigation.

Investigator Rippe conducted the following interviews: On 03/30/2023, at 1:29pm, with Administrator; on 04/24/2023, from 10:57am to 11:32am, with R1, Resident #3 (R3), Resident #4, and Administrator; on 05/15/2023, at 11:11am, with S1; on 05/16/2023, at 11:59am, with Administrator; and on 05/17/2023 with R1’s resident representative. In addition, Investigator Rippe reviewed Atascadero Police Department (APD) report #23-0431, San Luis Ambulance report, Twin Cities Community Hospital medical records and facility file documents related to R1 and R2, including the surveillance video of the 02/21/2023 incident and photos of R1’s injuries.

According to the APD report, police responded to the facility on 02/21/2023 at approximately 11:13pm. S1 stated to police that R2 hit R1 with a closed fist and R1 fell and hit their head. S1 stated R2 was standing next to R1 and R1 began scratching R2’s arms. S1 stated R2 hit R1 one time with a closed fist on the left side of forehead and R1 fell to the ground. S1 stated R1 got back on their feet and began scratching R2’s arms again. S1 stated R2 struck R1 in the face again with a closed fist, hitting R1’s left cheek bone. R1 lost balance and fell to the ground again. The officers attempted to speak with R1 but R1 was unable to articulate what happened. The report stated R1 has Dementia. The officers spoke with R2 who stated they were unsure if the altercation was with a female or male. R2 said they potentially kicked R1 in the head after R1 attacked R2 by grabbing R2. R2 was unable to articulate any further details of the incident. R1 was transported to Twin Cities Community Hospital and received stitches to forehead and cheek.

Twin Cities Hospital medical records review revealed that R1 was admitted to the hospital on 02/22/2023. The records documented R1 was in an altercation at the facility and R1 suffers from significant dementia. R1 had bleeding from their face and there was no known loss of consciousness. R1 had significant swelling to their left forehead and swelling to the left side of face. There was some dried blood noted to face and some ecchymosis to the palmar aspect of right hand. The CT scan of R1’s head and brain showed no signs of any skull fracture or intracranial bleed. R1 received stitches to close the wounds and was discharged back to the facility. Continued on 9099-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20230302100956

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: INGLESIDE ASSISTED LIVING	FACILITY NUMBER: 405850249
	VISIT DATE: 06/08/2023

NARRATIVE

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Facility records reviewed revealed that R1 had a diagnosis of dementia, with conditions of confused/disoriented and inappropriate/aggressive/sundowning behaviors. Facility notes revealed R1 had daily agitation and R1’s doctor, stated R1’s agitation was due to R1’s Alzheimer’s. R1’s agitation started to increase in February 2023 and R1 was prescribed Celexa due to the increase in agitation. The facility updated R1’s resident representative regarding the increase in agitation. R2’s primary diagnosis was listed as Alzheimer’s dementia, with conditions of confused/disoriented, and inappropriate/wandering/sundowning behaviors. There was no aggressive behavior documented in R2’s physician report or needs and services plan. R2 had no prior incidents of attempting to physically assault another resident.

Investigator Rippe reviewed the surveillance video of the 02/21/2023 incident. The video shows R2 standing on the outside of the desk counter next to R1. R3 was across the counter from R1 and R2 and R4 was sitting in a chair. S1 was behind the counter. The video shows R1 agitated and trying to grab the copy machine and reaching for S1’s arm. (S1 could not recall what R1 was frustrated about or saying. S1 stated R1 had been agitated from the start of the shift and the evening shift caregiver also stated to S1 that R1 had been agitated throughout their shift). The video shows R1 holding onto a chair and R2 talking to R1. The video shows R2 hit R1 and R1 falling to the ground. The video then shows R1 on the floor scooting towards R2. The video shows R2 sitting in a chair and using their left foot to kick R1 on their face and they fell back. S1 then came from behind the desk to get R1 off the floor and sit in a chair. S1 sat R1 face to face with R2 and then went back behind the desk. R1 got up from chair and reached for S1 (S1 stated they told R1 to stop grabbing S1 and told R1 to sit down as they were on the phone with the police at that time). The video then shows S1 leave the desk area (S1 stated they went to the front door to open the gate to allow APD to come in). The video shows S1 putting gloves on so they could look at R1’s injuries on face (S1 stated R1 would not let S1, APD or the paramedics clean their face).

The video shows S1 behind a desk and not assisting R1 for over three minutes during the incident. Per the Administrator, S1 could have comforted R1 and deescalated the situation between R1 and R2. The Administrator further stated, S1 should have kept R1 and R2 away from each other until police arrived. S1 was suspended due to the incident and no longer works at the facility. S1 stated the reason they remained behind the desk for over three minutes and didn’t help R1 after they were hit was because they were looking for the phone number for the paramedics that they had written down. S1 stated they did not witness R2 hitting R1 because they had their back turned to them. Continued on 9099-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20230302100956

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: INGLESIDE ASSISTED LIVING	FACILITY NUMBER: 405850249
	VISIT DATE: 06/08/2023

NARRATIVE

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Based on information obtained and reviewed during the investigation, the Department determined that the facility staff failed to provide adequate care and supervision to R1 by not intervening when R1 and R2 had a physical altercation, which resulted in R1 sustaining injuries. Therefore, the allegation “Neglect/Lack of Supervision - Due to lack of staff intervention, an altercation between residents resulted in injuries” is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).

Exit interview conducted, civil penalty issued, and the report and appeal rights given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20230302100956

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: INGLESIDE ASSISTED LIVING	FACILITY NUMBER: 405850249
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/09/2023 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan on how you will ensure appropriate care and supervision to residents. Submit to CCL by due date on 6/9/23.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff failed to intervene when R1 and R2 had an altercation which resulted in R1 sustaining injuries, which posed an immediate health and safety risk to residents 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: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC9099 (FAS) - (06/04)

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