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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421702010
Report Date: 10/05/2022
Date Signed: 10/05/2022 06:56:04 PM

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
07/15/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210715091930
FACILITY NAME:QUEJA RESIDENTIAL FACILITY FOR THE ELDERLYFACILITY NUMBER:
421702010
ADMINISTRATOR:QUEJA, DOROTHYFACILITY TYPE:
740
ADDRESS:845 PATTERSON ROADTELEPHONE:
(805) 934-3702
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 5DATE:
10/05/2022
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Dorothy Queja, Administrator/LicenseeTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident sustained injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver final findings for this investigation. LPA met with Dorothy Queja, Adminstrator/Licesee and explained the purpose of the visit.

On the allegation: Resident sustained injuries while in care. It was alleged that R1 had “open wounds” that R1’s medical provider felt were “inconsistent” with R1’s medical history.

R1’s medical documents indicate R1 has anemia, hypertension, hypothyroidism, hyperlipidemia, GERD, syncope/anemia, major depressive disorder, and dementia. Medical records indicate on 6/10/2021, home health’s plan of care for R1 includes physical therapy to help maintain and preserve R1’s skin integrity.

Adult Protective Services originally started an investigation into this case before they determined it was a facility licensed by Community Care Licensing.
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
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 2
Control Number 29-AS-20210715091930
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: QUEJA RESIDENTIAL FACILITY FOR THE ELDERLY
FACILITY NUMBER: 421702010
VISIT DATE: 10/05/2022
NARRATIVE
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On 7/5/2021, a medical professional visited R1 and observed “open wounds” which were not documented on the previous nurse visitation report. The medical professional asked the staff about the bruises and the staff stated R1’s “clothes caused the wounds” but did not provide any further information. The medical professional felt the observations were not consistent with the staff’s statement. On 7/6/2021, Santa Barbara County Sheriff’s Office conducted a welfare check on R1. The staff at the facility stated R1 has very thin skin and it tears easily. The staff stated R1 gets combative when dressing which cases skin tears and bruising. The Deputy stated R1 was sleeping when they arrived but they were able to observe R1’s legs and did not observe any evidence of abuse.
On 7/21/2021 and 8/10/2022, LPA interviewed staff for this investigation. Staff stated R1 was “hard to care for.” Staff stated when assisting with toileting needs, staff would assist with taking down and pulling up R1’s pants. Staff described that the injuries happened when pulling the resident’s pants up and down. Staff treated the skin tears with a wet towel, Neosporin, and bandages. Staff stated R1 would kick the staff when they helped change her. Staff stated they would pull up R1’s pants and R1 would kick, and when R1 kicked the pants left a mark and cut R1’s leg. Staff stated the resident was “difficult to change.” Staff stated they told a nurse R1’s pants scratched R1’s legs. Staff described R1 as bruising easily, marking easily, and having sensitive skin. Staff also stated R1 would bite them if they got too close. Staff were all consistent in their descriptions of R1 when interviewed.
On 7/1/2021, a Home Health nurse indicated they observed blood on R1’s sock and shin, and bloody gauze taped to the skin with bandaids. The nurse noted 5 different wounds on R1’s legs. Staff stated the wound occurred when R1 was wearing clothes that were too tight, and staff had been treating the wound with first aid. The nurse’s notes indicates R1 was unable to answer questions about the injuries.
On 9/12/2022, LPA interview R1’s physician. R1’s physician stated they did not observe the wounds first-hand, but knew of the concerns raised by other medical professionals. R1’s physician stated R1’s skin tears could have opened at some point but should close eventually. R1’s physician stated “elderly people can have skin tears from anything like even from rolling over in bed, its very possible.” R1’s physician stated they remembered the facility being attentive to R1. LPA interviewed a credible witness who stated they had never observed abuse in the facility and did not have any concerns about abuse. Administrator stated they spoke with R1’s family member when the incident occurred, and R1’s family member did not believe the injuries were intentional. LPA interviewed 4 residents and R'1s family member who also confirmed residents were well cared for.
Based on the evidenced obtained, there is insufficient evidence to suggest staff abuse led to R1 sustaining injuries. Therefore the allegation is Unsubstantiated at this time.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
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