425800464-7-13-2021-29-AS-KBUY-C4VT7N-20210713142901

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425800464
Report Date: 07/13/2021
Date Signed: 07/13/2021 09:24:12 AM

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
10/29/2019 and conducted by Evaluator Toan Luong

COMPLAINT CONTROL NUMBER: 29-AS-20191029112919

FACILITY NAME:	VISTA DEL MONTE		FACILITY NUMBER:	425800464
ADMINISTRATOR:	DOUGLAS TUCKER		FACILITY TYPE:	741
ADDRESS:	3775 MODOC ROAD		TELEPHONE:	(805) 687-0793
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93105
CAPACITY:	266	CENSUS: 190	DATE:	07/13/2021
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Douglas Tucker, Executive Director		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Facility has insufficient staff to meet the residents' needs.
Facility staff failed to meet the needs of the residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lyndia Sager conducted a subsequent complaint investigation to deliver final investigation findings telephonically with Douglas Tucker, Executive Director, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.
On 10/29/19, the Department received a complaint with the allegations that the Summer House Memory Care portion of the facility was understaffed with a total of 18 residents and only 2 staff to care for the residents. Many of the residents were a fall risk, confused, disoriented, wanderers, needed toileting assistance, and were sometimes left unattended and had to wait for assistance due to insufficient staffing. Multiple times the residents called the staff for assistance, but due to the lack of staff they were left unattended for an extended time.
On 11/14/19 at 2:10pm., LPA Kontilis conducted an unannounced initial complaint visit and requested and obtained pertinent documents relating to the allegations. LPA Kontilis also conducted brief interviews with staff.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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-20191029112919

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: VISTA DEL MONTE	FACILITY NUMBER: 425800464
	VISIT DATE: 07/13/2021

NARRATIVE

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On 4/19/21, LPA Sager interviewed the Executive Director at 3:35pm. LPA interviewed staff on 05/11/21 at 3:52pm; 05/13/21 from 2:47pm to 4:19pm; 05/21/21 from 9:38am to 5:28pm. LPA interviewed a family member on 05/14/21 at 3:17pm. LPA interviewed the Director of Nursing on 05/20/21 at 2:09pm.

LPA reviewed the October 2019 staff schedule for the Summer House Memory Care. The schedule reflects there is one LVN assigned to each shift (a.m., p.m. and noc). There are two med techs for the a.m. shift. There are two med techs for the p.m. shift except for the dates 10/27/19 through 10/31/19 shows no med techs on schedule. There are two CNA staff for the a.m. shift except for the dates 10/4/19, 10/14/19, 10/28/19 shows one staff on schedule. There are two CNA staff for the p.m. shift except for the dates 10/01/19 and 10/02/19 shows no CNA staff on schedule; 10/3/19 through 10/06/19 and 10/31/19 shows one CNA staff on schedule. There are two CNA staff for the noc shift except for 10/3/19, 10/4, 10/11, 10/17, 10/18, 10/24, 10/25, and 10/31/19 shows one CNA staff on schedule.

LPA reviewed the resident roster for Summer House Memory Care dated 10/31/19 which reflects a total of 19 residents. LPA reviewed a random sampling of six Summer House Memory Care health and wellness records. Five of the six residents are non-ambulatory, incontinent and need either complete toileting assistance or require additional time. Five of the six residents have Dementia and cannot leave the facility unassisted. One of the residents has a wandering behavior. Four of the residents need transfer assistance. Two of the residents need a two-person assist.

Staff interviews revealed that during October 2019 there were at times not enough staff to care for all the memory care residents in Summer House Memory Care. Staff interviews revealed at times residents were left unattended while staff cared for other residents. Staff interviews revealed residents would attempt to get up on their own instead of waiting for staff assistance and then falls would occur. Staff interviews revealed two staff were not enough based on the needs of the residents. When staff called out sick, some staff had to work double shifts or would be the only staff on shift to care for the residents. A family member interviewed witnessed numerous times that residents who needed assistance had to wait while staff were helping other residents. The family member also witnessed having to wait for staff assistance to come to the room after pushing the call button several times.

Information obtained from the Administrator and Director of Nursing states they had adequate staffing in the Summer House Memory Care in October 2019.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20191029112919

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: VISTA DEL MONTE	FACILITY NUMBER: 425800464
	VISIT DATE: 07/13/2021

NARRATIVE

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Based on the information obtained during the course of the investigation, there is sufficient evidence to support the allegations that in October 2019 facility staff failed to meet the needs of the residents due to an insufficient amount of staff in the Summer House Memory Care. The above allegations are deemed substantiated.

Deficiencies issued on 9099-D, exit interview was conducted with the Executive Director, and a copy of the report was provided via email for signature. Appeal Rights emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20191029112919

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: VISTA DEL MONTE	FACILITY NUMBER: 425800464
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 07/19/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements – General (a) (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...	1 2 3 4 5 6 7	Executive Director will review the service plans for each resident, determine what level of resident needs are necessary and provide sufficient staffing. Executive Director will submit staff roster for Summer House Memory Care to reflect adequate 24/7 staffing. Executive Director will submit plan to CCL by 7/19/21.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and documents reviewed, the licensee failed to ensure there was an adequate amount of Summer House Memory Care staff in October 2019 to meet the resident needs which posed a potential 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
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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: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC9099 (FAS) - (06/04)

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