425802106-3-30-2022-29-AS-KBUY-CD2253-20220330170451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802106
Report Date: 03/30/2022
Date Signed: 03/30/2022 02:47:36 PM

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
08/30/2021 and conducted by Evaluator Toan Luong

COMPLAINT CONTROL NUMBER: 29-AS-20210830163115

FACILITY NAME:	MARIPOSA AT ELLWOOD SHORES		FACILITY NUMBER:	425802106
ADMINISTRATOR:	PETER JOHN BONILLA		FACILITY TYPE:	740
ADDRESS:	190 VIAJERO DR		TELEPHONE:	(805) 265-4327
CITY:	GOLETA	STATE: CA	ZIP CODE:	93117
CAPACITY:	99	CENSUS: 90	DATE:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Denay Ramirez		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Neglect/Lack of Supervision: Facility Resident #1 (R1) sustained a hematoma to frontal lobe, a small skull fracture, and a subdural hematoma after 3 falls from 08/07/2021- 08/16/2021, which resulted from the facility’s lack of supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Toan Luong conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Business Administrator Denay Ramirez and explained the reason for the visit.

On 08/30/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that facility Resident #1 (R1) sustained a hematoma to frontal lobe, a small skull fracture, and a subdural hematoma after 3 falls from 08/07/2021- 08/16/2021, which resulted from the facility’s lack of supervision. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Jose Santana.
On 08/31/2021, from 2:28pm to 3:30pm, Licensing Program Analyst (LPA) Arien Diaz conducted an initial 10-Day complaint visit. The visit was conducted on-site with Peter Bonilla, Administrator. During the visit, LPA Diaz toured the facility with Administrator and requested documents pertinent to the investigation. (Continued on 9099-C)

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: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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 4

Control Number 29-AS-20210830163115

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: MARIPOSA AT ELLWOOD SHORES	FACILITY NUMBER: 425802106
	VISIT DATE: 03/30/2022

NARRATIVE

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(Pg2) The Administrator was notified that the complaint was referred to Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Jose Santana. The LPA determined further investigation was required.

On 09/07/2021, Investigator Santana conducted interviews with the reporting party, R1’s representative and Santa Barbara Long Term Ombudsman Program (LTCOP); on 10/05/2021, with facility staff; on 10/06/2021, with facility staff, Central Coast Home Health and Hospice, and attempted an interview with R1 (R1 was not able to be interviewed due to R1 could not provide the correct answers to the 10 Step Investigative Interview Protocol); on 11/03/2021, with R1’s former Primary Care Physician; on 11/05/2021, with Witness #1 (W1); on 11/19/2021, with Witness #2 (W2) and Central Coast Home Health Physical Therapist; and on 11/18/2021 and 11/24/2021, attempted interview/left message with R1’s Primary Care Physician.

Investigator Santana reviewed copies of facility records and medical records related to R1. The information indicated R1, with a history of ataxia (impaired balance or coordination), Alzheimer’s dementia, and a fall risk, was admitted to the facility on 07/27/2021. R1 required a “Level 2” care program in memory care, based on a comprehensive assessment. The highest level in memory care is a Level 3. The physician report, dated 06/16/2021, listed the primary diagnosis as spinocerebellar ataxia for which R1 required a walker. Care and supervision needed for this condition was for R1 to receive medication and to be watched for falls. R1 was listed as having dementia and as being confused and verbally aggressive. R1 had the capacity to take care of toileting needs but required supervision with bathing and grooming. R1 had motor impairment that manifested as walking with a tremor, but could transfer independently to and from bed. Additionally, the Investigator reviewed R1’s preplacement appraisal, service plans, narrative charting, residency agreement, unusual incident report for the 08/08/2021 fall, internal incident reports, shift reports, physician communications, staff schedule and assignments, Emergency Medical Services (EMS) records, 911 call recordings, Santa Barbara Cottage Hospital records, Goleta Valley Cottage Hospital records, and Central Coast Home Health records.

On 09/07/2021, Investigator Santana contacted the Santa Barbara Long Term Care Ombudsman Program (LTCOP) and was informed they would not be investigating the present allegation due to consent had not been received from R1’s representative. On 09/10/2021, the investigator contacted the Santa Barbara County Sheriff’s Office, Criminal Records, to inquire if there was a crime report for the present allegation. There was no crime report related to R1.
(Continued on 9099-C)

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20210830163115

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: MARIPOSA AT ELLWOOD SHORES	FACILITY NUMBER: 425802106
	VISIT DATE: 03/30/2022

NARRATIVE

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(Pg3) It was reported that R1 was brought into the Emergency Department at Goleta Valley Cottage Hospital on three (3) separate occasions. The first visit was on 08/07/2021, after R1 was found on the floor at the facility. R1 sustained a small hematoma to the left frontal lobe and was discharged back to the facility. The second visit occurred on 08/08/2021, after R1 was found on the bathroom floor. R1 suffered a laceration to right parietal region with controlled bleeding and a skull fracture and was transferred to Santa Barbara Cottage Hospital because of a subdural hematoma. The third visit occurred on 08/16/2021, after another unwitnessed ground level fall. A CT scan of the brain found a right anterior and posterior scalp contusion and hematomas.

Based on the facility interviews, it appears the first fall, on 08/07/2021, occurred minutes after a caregiver had checked on R1 and that the fall perhaps could not have been foreseen because R1 had not previously fallen at the facility. However, a review of facility records revealed that the facility failed to follow its standard protocol in response to this first fall. The 48-hour monitoring and narrative charting did not take place for the entire designated time period, and there was no reassessment done despite R1’s continued agitation and attempts to leave the facility following the return from the hospital. While a MedTech contacted R1’s physician to report this agitation, there is no additional documented response to address R1’s behavior prior to the subsequent fall on 08/08/2021. The facility did not adequately address R1’s agitation and exit-seeking behaviors, which posed a risk to R1’s safety. R1 was only provided a one-on-one caregiver after the third hospitalization on 08/16/2021. Furthermore, no bed alarm was procured until the hospital insisted that one be provided after R1’s second fall. The allegation that R1 sustained head injuries requiring hospitalization from multiple falls, as a result of the facility’s Neglect/Lack of Supervision, is therefore Substantiated at this time.
A $500 immediate civil penalty is assessed today. The Business Manager was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).
Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20210830163115

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: MARIPOSA AT ELLWOOD SHORES	FACILITY NUMBER: 425802106
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 04/01/2022 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with	1 2 3 4 5 6 7	Licensee will submit a written action plan regarding proper resident care and supervision to CCL by 4/1/22
	8 9 10 11 12 13 14	the section cited above. (R1) was not provided the proper supervision to ensure R1’s safety. R1 had a history of falls, which led to multiple falls causing R1 to sustain injuries requiring hospitalization, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
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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: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

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