425802109-12-18-2023-29-AS-KBUY-CYQ2TC-20231220164030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802109
Report Date: 12/18/2023
Date Signed: 12/18/2023 05:49:49 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
07/21/2021 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20210721162941

FACILITY NAME:	A CASA RHODA 2		FACILITY NUMBER:	425802109
ADMINISTRATOR:	DEMONTEVERDE, NORMA B		FACILITY TYPE:	740
ADDRESS:	165 SANTA ANA AVENUE		TELEPHONE:	(805) 964-4236
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	6	CENSUS: 6	DATE:	12/18/2023
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Rhoda Demonteverde, Licensee		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Due to neglect, resident developed UTI and sepsis
Facility did not assist resident with toileting needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to issue final findings for the complaint allegations above. LPA met with Rhoda Demonteverde, Licensee and explained the purpose of the visit. During the investigation, LPA Kontilis reviewed relevant documents, and conducted resident interviews on 7/30/2021, and staff interviews on 7/30/2021, 8/2/2021, and 10/4/2021.

On the allegations: Due to neglect, resident developed UTI and sepsis, and Facility did not assist resident with toileting needs. It was alleged that staff did not assist Resident 1 (R1) with using the restroom at night and instead put a nighttime diaper on the resident. It was also alleged that staff did not change R1’s diaper first thing in the morning. R1 was admitted to the hospital on 7/7/2021 due to a Urinary Tract Infection (UTI) that resulted in septic shock. R1 was previously hospitalized on 3/8/2021 for a UTI and sepsis. It was alleged the facility’s bathroom log indicated R1 was taken to the bathroom every hour. R1’s diagnoses include dementia. LPA interviewed R1 who indicated that they were happy with the care received at the facility. Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210721162941

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: A CASA RHODA 2	FACILITY NUMBER: 425802109
	VISIT DATE: 12/18/2023

NARRATIVE

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R1 stated staff check to see if they are dry and does not feel neglected and feels safe at the facility. Staff interviewed stated they take R1 to the bathroom often, but do not take them if they are too sleepy or tired. Staff stated they spot check R1 every few hours at night. Recently, they have been taking R1 to the bathroom every 2 hours because they are not completely voiding and are wetting their brief at night. Staff stated R1 does not want to get up at night, and sleep deeply to where they have trouble waking R1. Staff stated they roll R1 side to side to change them. Administrator stated and LPA confirmed the documents show they are taking R1 to the bathroom every 2 hours. It was previously every hour, but now it is every two hours. On 7/6/2021, staff started checking R1 every hour and asked R1’s doctor to ensure R1 had a standing order for a urine test. They took the test and submitted it at noon, and in the afternoon, the doctor called that the test indicated bacteria in the urine and the urine needed further evaluation. The doctor did not prescribe antibiotics. Staff noticed around 5:35pm that R1 was weak and called 9-1-1. R1 went to the hospital that day and was discharged at 7:30pm with antibiotics for a UTI. After R1 returned from the hospital, toileting was scheduled for every hour of every day starting at 6am. Staff asked R1 if they needed to use the bathroom, but sometimes R1 would say they did not have to go. On 7/7/2021, staff observed R1 to still be weak and they called 9-1-1 again. Paramedics stated it was normal to be weak from antibiotics, and R1 stated they were ok and did not want to go to the hospital. Staff insisted R1 be taken to the hospital, where R1 was admitted for septic shock. R1 was discharged on 7/15/2021 and was prescribed antibiotics. Staff confirmed R1 previously had sepsis on 3/5/2021 and was treated at home with new antibiotics. R1 has an autoimmune disorder that is being treated with a medication that weakens the immune system, which is why they are especially prone to UTIs and sepsis. Both R1’s primary care physician and neurologist have explained this to facility staff. Administrator pointed out R1 had no sores, no rashes or redness in their private area, which helps support that R1 has good hygiene and proper care, but the UTI and sepsis are being caused by the autoimmune disorder medication. Based on the information obtained, it appears that R1 was prone to UTIs and no evidence of neglect was found. Therefore the allegations are Unsubstantiated at this time.

Exit interview, copy of report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC9099 (FAS) - (06/04)

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