405850480-6-10-2024-29-AS-KBUY-D6F4T3-20240620192229

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850480
Report Date: 06/10/2024
Date Signed: 06/10/2024 10:49:32 AM

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
12/28/2022 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20221228105128

FACILITY NAME:	OAKS AT PASO ROBLES, THE		FACILITY NUMBER:	405850480
ADMINISTRATOR:	PETER J BONILLA		FACILITY TYPE:	740
ADDRESS:	526 S RIVER ROAD		TELEPHONE:	(805) 239-5851
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	120	CENSUS: 87	DATE:	06/10/2024
		UNANNOUNCED	TIME BEGAN:	07:34 PM
MET WITH:	Administrator - Carl Meyer		TIME COMPLETED:	11:15 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care.
Facility staff is not maintaining proper fire safety precautions at the facility.
Residents are not provided proper food service.
Staff do not order resident's medication in a timely manner.
Staff did not assist resident with their doctor's appointment.

INVESTIGATION FINDINGS:

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At 8:00am on 06/10/2024, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to delivering final findings to the allegations to this complaint, as well as a second complaint, and a complaint visit on a thrid complaint. LPA met with facility Administrator, Carl Meyer, announce who he is and the reason for the visit.
As to the allegation of, “Resident sustained pressure injury while in care.” It was alleged that resident was neglected and obtained bed sores. It was discovered through documentation and interviews that on 01/17/2023, LPA Jeffries reviewed all R13 medical files and documentation and discovered a facility Health and Service Evaluation report indicated that they were tracking “current or historical skin condition” (nothings specific specified) dated 10/16/2022. On 12/01/2022 Resident 13 (R13) had been diagnosed with COVID, documented on LIC624(Unusual Incident/Injury Report), with notification to R13’s Physician, Responsible Party, and submitted to Community Care Licensing. On 12/11/2022 R13 was observed with blisters on both of his hips, and presented symptoms of pneumonia, this was documented by facility Resident Care Director who called Emergency Services to transport R13 to the hospital. CONTINUED on LIC9099-C

Unsubstantiated

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: 06/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2024

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 4

Control Number 29-AS-20221228105128

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: OAKS AT PASO ROBLES, THE	FACILITY NUMBER: 405850480
	VISIT DATE: 06/10/2024

NARRATIVE

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This was documented by the facility on an LIC624 (Unusual Incident/Injury Report), with notification to R13’s Physician, Responsible Party, and submitted to Community Care Licensing. On 01/12/2023 LPA Jeffries interviewed Staff 1, and 2 (S1, S2) who both stated that they did not observe R13 to have any rash or soars on his body before 12/01/2022. Interviews on 01/12/2023 with S1-S6 stated that residents who are on COVID protocols during this time residents are checked and accessed by direct care staff a minimum of 6 times per day. On 01/12/2023, LPA interviewed R1-R12, all stated no issues with care, and no issues with facility. R13 was not available for interview. Based on documentation of Care evaluation in October, and LIC624’s in November of 2022, resident care protocols during COVID outbreak, and Resident and Staff interviews, there is not enough evidence to support the allegation of, “Resident sustained pressure injuries while in care.” and is unsubstantiated at this time.

As to the allegation of, “Facility staff is not maintaining proper fire safety precautions at the facility.” It was alleged that all of the fire extinguishers are overdue for their annual inspection/certification. It was discovered through observation, interviews and documentation that on 01/04/2023 and 01/12/2023, LPA Jeffries conducted a full facility walkthrough and observed more than 30 fire extinguishers throughout the entire facility all to be tagged and in working pressure range. LPA also observed and collected documentation of Inspection, Testing, and Maintenance of facilities integrated sprinkler system performed by Alpha Fire Unlimited on 08/23/2022. LPA Jeffries also collected documentation of last fire drills conducted on 12/28/2022 and 12/29/2022 to cover all three floors of the facility, which exceeds regulations standars. At this time there is not enough evidence to support the allegation of, “Facility staff is not maintaining proper fire safety precautions at the facility” and is unsubstantiated at this time.
As to the allegation of, “Resident are not provided proper food service.” It was alleged that Employees often do not wear their masks while serving meals and lack of staffing in the dining. It was discovered through interviews and observation that on 01/12/2024 LPA conducted interviews with R1-R12 all residents had no issues with food or food service, and staffing was also not an issue with Resident interviewed. On 01/04/2023 and 01/12/2023 LPA Jeffries made observations of staff who were all masked during respective visits. On 01/12/2023, LPA Jeffries interviewed S1-S6 stated that they have been following infection control policies and have been wearing appropriate Personal Protective Equipment (PPE) at all times while working. On 01/17/2023, LPA Jeffries collected and reviewed full facility schedule for December of 2022 and noted that call offs were noted but did not impact service in dining at the facility. At this time, there is not enough evidence to support the allegation of, “Residents are not provided proper food service.” and is unsubstantiated at this time. CONTINUED on LIC9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221228105128

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: OAKS AT PASO ROBLES, THE	FACILITY NUMBER: 405850480
	VISIT DATE: 06/10/2024

NARRATIVE

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As to the allegation of, “Staff do not order resident's medication in a timely manner.” It was alleged that medication was running out and not ordered in a timely manner. It was discovered through documentation, and interviews that on 01/12/2022, LPA interview R1-12 who all stated they have never had an issue with medication, never missed a dose of medication, or had the wrong medication provided while at this facility. On 01/12/2023 LPA Jeffries interviewed S1 and S6 who stated that medication have been coming on time and residents in care have not missed any medications in all medication passes the their knowledge. On 01/17/2023, LPA Jeffries reviewed Medication Administration Record (MAR) for 83 residents in care during the month of December 2022 and January 2023 and noted that there were zero missed medications of that two-month medication review and no incident reports submitted for medication errors. At this time there is not enough evidence to support the allegation of, “Staff do not order resident’s medication in a timely manner.”

As to the allegation of, “Staff did not assist resident with their doctor's appointment.” It was alleged that two residents had issues with toenails have been neglected to the point of both having nail fungus. This issued was addressed in a separate complaint (29-AS-20230320095114) as follows:
As to the allegation of, “Staff failed to observe resident’s nail care needs.” It was alleged that two residents were neglected to the point of having nail fugus. It was discovered through interviews, documentation and observation that on 03/23/2023, LPA conducted interview with Administrator, Administrator stated that the Podiatrist, Dr. Tisngson, DPM was at this facility today (03/23/2023) and was scheduled to treat two residents (R1 and R2). Administrator stated that R1 had a visit with the Podiatrist and R2 refused Podiatrist treatment on this visit. Administrator stated the Podiatrist routinely visit the facility monthly. On 03/23/2023, LPA attempted to interview R1 and R2. Both R1 and R2 could not answer basic cognitive screening questions. On 03/30/2023, LPA conducted a full review of R1 and R2’s medical files. R1 had a ‘Podiatric Evaluation and Treatment’ conducted by Dr. Tisngson, DPM, singed and dated on 03/23/2023. R2 had medical chart notes stating, “RSD (Podiatrist) tried to check residents’ toenail today, but resident refused….” Additionally, R2 had chart notes on 03/16/2023, that stated, “Resident went to see a Podiatrist today …” On 03/23/2023, LPA interviewed, Direct Care Staff 1-4 (S1, S2, S3, and S4). S1-4 all stated that R2 does not respond to hygiene prompts, and refuses self-care help on a daily basis. Interviews of R3, R4, R5, and R6, all say that facility care staff do a good job at addressing any issues they have and feel safe and cared for in this facility. On 03/23/2023, LPA also viewed fire extinguishers throughout the facility to be in regulation compliance (87203), staffing to be in sufficient numbers and resident counsel meeting being conducted monthly with scheduled meeting posted on facility bulletin board. At this time there is not enough evidence to support the allegation of, “Staff failed to observe resident’s nail care needs.” and is unsubstantiated at this time.
CONTINUED on LIC9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20221228105128

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: OAKS AT PASO ROBLES, THE	FACILITY NUMBER: 405850480
	VISIT DATE: 06/10/2024

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 26 27 28 29 30 31 32	Based on previous findings above, there is not enough evidence to support the allegation of, “Staff did not assist resident with their doctor’s appointment.” and is unsubstantiated at this time. Exit interview, report read, 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: 06/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2024

LIC9099 (FAS) - (06/04)

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