421703604-1-23-2024-29-AS-KBUY-CZYT9S-20240130133226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 421703604
Report Date: 01/23/2024
Date Signed: 01/23/2024 02:14:57 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
08/24/2023 and conducted by Evaluator Brian Phillips

COMPLAINT CONTROL NUMBER: 29-AS-20230824134837

FACILITY NAME:	ORCUTT BOARD AND CARE HOME		FACILITY NUMBER:	421703604
ADMINISTRATOR:	ANNIE YAGUE		FACILITY TYPE:	740
ADDRESS:	263 CRESCENT AVE.		TELEPHONE:	(805) 934-2586
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY:	6	CENSUS: 4	DATE:	01/23/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Annie Yague, Administrator/Licensee		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff restrained resident.
Staff left resident in soiled clothing.
Due to staff neglect, resident developed pressure injury while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 01/23/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit to the facility above to issue final findings. LPA arrived at the facility, met with Administrator/Licensee Annie Yague, and announced the purpose of the visit.

On the allegation: Staff restrained resident. It is alleged Resident #1 (R1) was found in their bed with bungee cords attached to each wrist, with cloth under the bungee cords. The bungee cords were attached from R1’s wrists to the bed frame, and R1 was allegedly restrained. It is alleged that two (2) Staff members were standing next to R1’s bed, “hovering over” R1. The allegation stated that the Staff members voiced R1 is combative, and Staff use the bungee cords so R1 cannot commit self-harm. It is alleged that bungee cords could also be seen hanging off the side of R1’s bed in each corner of the bed. It is alleged that the Staff members removed the bungee cords from R1’s wrists and took them out of R1’s bedroom with them, but that more bungee cords were seen located in R1’s bedroom drawer.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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 5

Control Number 29-AS-20230824134837

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ORCUTT BOARD AND CARE HOME	FACILITY NUMBER: 421703604
	VISIT DATE: 01/23/2024

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

On 08/28/2023, LPA conducted an unannounced initial complaint visit to the facility above. LPA conducted thorough observation of each resident room including the room of R1. LPA also observed all storage areas in each resident bedroom as well as storage areas in the common areas of the facility such as cabinets, drawers, closets, storage room(s), etc. During the initial complaint visit on 08/28/2023, LPA did not observe bungee cords of any kind anywhere in the facility. LPA has frequently visited the facility including the dates of 07/18/2023, 08/14/2023, 08/28/2023, 10/12/2023, 12/05/2023, and 01/04/2024. At no point during any in-person visit to the facility by LPA were any bungee cords observed within the facility nor were any signs of trauma to R1’s wrists observed by LPA while R1 was in the facility. On 08/31/2023, LPA interviewed a Staff member from a Hospice Agency who had frequent contact with R1 on at least a weekly schedule within the past few months. Witness #1 (W1) stated that there was only one (1) individual who had allegedly observed all the allegations, and that W1 has been to the facility numerous times in the past few months and had not seen anything close to what the allegations are describing. W1 stated to LPA that they had visited the facility many times before with no concerns noted. LPA also spoke with other Staff from the Hospice Agency who have been into the facility in the recent months and no Staff member could corroborate seeing anything like what the allegations are describing. W1 was surprised to hear what the allegations described, as they have been in the facility on a consistent basis in recent months with no concerns regarding any restraints. According to W1, they went to see R1 on the afternoon of 08/24/2023, with no bungee cords seen in the resident's room. W1 checked the drawers in R1’s room and checked the closet but could not find any bungee cords at all. W1 stated to LPA that they had never observed signs of trauma to R1’s wrists or had any concerns with the care of R1. Other Hospice Agency Staff interviewed by LPA stated that R1 occasionally needed prompting and redirecting of negative behaviors such as lashing out and being upset at being woken up. However, they had never observed or heard of any Facility Staff members using any type of physical restraints on R1 or that R1 would self-harm. On 08/28/2023 and 10/12/2023, LPA interviewed Staff members of the facility about the allegation. No Staff member of the facility stated that any bungee cords were used on R1 at all. Staff members stated that R1 was on Hospice Care, medicated, and never physically restrained with anything. All Staff members interviewed stated that they did not restrain R1 with bungee cords to prevent R1 from committing self-harm. On 08/28/2023, LPA conducted record review of facility documentation for R1. Records reviewed for R1 included the Centrally Stored Medication and Destruction Record kept by the facility for all residents in care, physician’s notes for R1, Resident Appraisal for R1, Statements of Patient Advocates or Ombudsman, Physician Orders for R1 including Primary & Secondary diagnosis, Appraisal Needs & Services Plans (ANS), Physicians Reports for Residential Care Facilities for the Elderly (RCFE), and Emergency Information. Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20230824134837

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ORCUTT BOARD AND CARE HOME	FACILITY NUMBER: 421703604
	VISIT DATE: 01/23/2024

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

LPA also received Hospice Care documentation for R1 from R1’s Hospice Agency on 08/28/2023. LPA found no documented evidence that R1 was at risk for committing self-harm, nor any evidence of R1 needing physical restraints of any kind.

Based on the information obtained, there was Insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff left Resident in soiled clothing. It is alleged that R1 was saturated in urine with a brief that weighed one (1) pound, incontinent of stool, and had had dried feces on their pillowcase and sheets. It is alleged that there was a strong odor of urine in the room of R1 and was concentrated. Allegedly urine went through R1’s clothing, sheets, and onto R1’s mattress. It is alleged R1 did not have hygienic cleaning wipes in their room, even though they had received a delivery that contained wipes from the Hospice Agency of R1. It is alleged that Staff of the facility had to bring in hygienic cleaning wipes from another resident’s room, but there was dried feces on the package.

LPA has frequently visited the facility including the dates of 07/18/2023, 08/14/2023, 08/28/2023, 10/12/2023, 12/05/2023, and 01/04/2024. At no point during any physical visit to the facility did LPA observe any resident saturated with urine and/or feces anywhere in the facility. On 07/18/2023, LPA conducted a Required Annual Facility Evaluation Inspection and Report. The LPA observed all resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are six (6) designated resident rooms. All the resident rooms have an individual bed for one (1) resident. Each closet/storage area in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for residents. During multiple visits to the facility by the LPA on 07/18/2023, 08/14/2023, and 12/05/2023, LPA observed Staff members actively cleaning and sanitizing different rooms of the facility including restrooms and resident bedrooms. On 08/31/2023, LPA interviewed W1 who stated that during the frequent visits to see R1 under the authority of an outside Agency, they have been in the facility many times before with no concerns noted about incontinence. W1 went to see R1 on 08/24/2023, and R1’s bed was clean & dry with no signs of feces anywhere in the bedroom and no observable odor of urine by W1. On 08/28/2023, LPA interviewed Staff members of the facility who stated that all residents are regularly cleaned/bathed, and checked according to a schedule if there are risks of incontinence. Staff stated that extra incontinence materials are stored in resident bedrooms and/or storage areas in the common areas of the facility. Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20230824134837

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ORCUTT BOARD AND CARE HOME	FACILITY NUMBER: 421703604
	VISIT DATE: 01/23/2024

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

All Staff members interviewed by LPA denied leaving R1 in urine-soaked clothing and/or bed, and all Staff members interviewed by LPA stated that no resident would be left in feces, nor would feces be on any item used to clean any resident. On 08/28/2023, LPA interviewed residents of the facility who all stated they had not seen feces being left in a bedroom or on anything in the facility. Residents interviewed by LPA all stated they are cleaned by Staff and/or checked on by Staff on a regular basis.

Based on the information obtained, there was Insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Due to staff neglect, resident developed pressure injury while in care. It is alleged that R1 was observed with a pressure injury to R1’s bottom. It is alleged that the pressure injury to R1 was “0.5 pea size.” According to the allegation, the Reporting Party (RP) does not have details as to how R1 sustained their pressure injury.

On 08/31/2023, LPA interviewed W1 and members of the Home Hospice Agency (HHA) that had contact with R1 and physically visited the facility. According to W1, the Home Hospice Agency (HHA) of R1 applied barrier cream onto coccyx area generously, where skin was reddened. W1 went to see R1 on 08/24/2023 and stated that R1 had a Stage 2 pressure injury to R1’s coccyx. On 08/28/2023, LPA conducted record review of facility documentation for R1. Records reviewed for R1 included the Centrally Stored Medication and Destruction Record kept by the facility for all residents in care, physician’s notes for R1, Resident Appraisal for R1, Statements of Patient Advocates or Ombudsman, Physician Orders for R1 including Primary & Secondary diagnosis, Appraisal Needs & Services Plans (ANS), Physicians Reports for Residential Care Facilities for the Elderly (RCFE), and Emergency Information. LPA also received Hospice Care documentation for R1 from R1’s Hospice Agency on 08/28/2023. R1 was admitted to Hospice Care with a Home Hospice Agency on 03/10/2023. On 08/28/2023, when interviewed by LPA, the Reporting Party (RP) did not have details as to how R1 sustained their pressure injury. On 08/28/2023, LPA interviewed Staff members of the facility about this allegation who all stated R1 was treated for a reddened area/wound on their bottom regularly by R1’s Home Hospice Agency (HHA) and had antibiotics (cream). R1 received a patch and routine cleaning from a Hospice nurse. The facility staff stated they would rotate R1 every 2 hours at minimum. Record Review of Hospice Care Agency documentation and interviews with Hospice Care Agency Staff indicated that R1 had redness/irritation/wound on their coccyx/tailbone area which was treated weekly by Hospice Agency providers. Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20230824134837

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ORCUTT BOARD AND CARE HOME	FACILITY NUMBER: 421703604
	VISIT DATE: 01/23/2024

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

According to HHA statements from a visit with R1 on 08/16/2023, the skin integrity of R1 was intact, however the skin around the coccyx area was reddened and inflamed which constituted a Stage 1 pressure injury. The HHA Staff applied barrier cream onto the coccyx area generously, where skin was reddened. According to HHA statements from a visit with R1 on 08/23/2023, R1 was observed with a Stage 2 pressure injury to their coccyx. Records show both the facility and Hospice Agency were providing care for the pressure injury to R1. Hospice Agency personnel interviews did not reveal any indications of facility Staff neglect. Facility staff interviewed indicated they regularly checked/turned R1 as per the Hospice Care Plan for R1. Hospice Agency personnel stated to LPA that R1 occasionally needed prompting and redirecting of negative behaviors such as lashing out and being upset at being woken up which was believed to cause friction of R1’s fragile skin rubbing against clothing or bedding, and traction (pulling or stretching of skin) from sliding down R1’s inclined bed. There is no evidence either through record review of Facility and HHA documentation or interviews with Staff members at either the facility or the HHA that R1 received the pressure injury due to Staff neglect.

Based on the information obtained, there was Insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued to the facility.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5