425802121-1-12-2023-29-AS-KBUY-CN8RF2-20230119115825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802121
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:41:26 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
01/24/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20220124095425

FACILITY NAME:	VILLA GARDENS		FACILITY NUMBER:	425802121
ADMINISTRATOR:	JENNIFER FIDEL		FACILITY TYPE:	740
ADDRESS:	1510 CALLE MIRO		TELEPHONE:	(805) 430-8906
CITY:	LOMPOC	STATE: CA	ZIP CODE:	93436
CAPACITY:	6	CENSUS: 0	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Juanito and Eden Fidel, Staff		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not able to meet the needs of residents
Resident sustained pressure injuries while in care

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver findings for the above allegations. The investigation was started on 02/01/2022 by LPA Toan Luong. LPA's requested relevant documents and interviewed staff and Administrator on 02/01/2022 and 01/12/2023. LPA Olson met with Juanito and Eden Fidel, Staff and Jane Castaniga, Licensee over the phone and explained the reason for the visit.

On the allegation: Staff are not able to meet the needs of residents. The reporting party was concerned that the night staff were unable to properly care for the residents. The reporting party stated a staff told them that it was “too much,” they are unable to reposition R1 due to being older, and the Reporting party also stated that R1’s catheter gets frequent infections, and R1 is underweight. LPA reviewed R1’s Physician’s Report dated 11/18/2021 indicates R1 is unable to bathe, groom, or dress self, needs minimum assistance to care for own toileting needs.
Continued on 9099-C

Substantiated

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: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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-20220124095425

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: VILLA GARDENS	FACILITY NUMBER: 425802121
	VISIT DATE: 01/12/2023

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 Olson reviewed R1’s Preplacement Appraisal Information which states they need 1-2 person assistance with toileting, uses a catheter and is a minimum 1 person assist. LPA reviewed R1’s Appraisal/Needs and Services Plan dated 11/19/21 which states R1 needs assist with bathing, grooming, dressing, and minimum assist with toileting, and needs transfer to and from bed.

LPA Luong interviewed Administrator/Licensee on 02/01/2022. Administrator stated R1 was admitted with a stage 1 pressure injury and it may have become a stage 2. Administrator also stated R1 does not cooperate with turning but is able to turn themselves. At 10:35 AM LPA Luong asked if resident was able to reposition themselves. LPA observed R1 grab the arm rail and was unable to turn. Administrator had to assist R1 to turn in bed. At 11:12 AM LPA Luong observed staff 1 (S1) and Administrator reposition R1. R1 was facing the left side and grabbing the bed rails. R1 was unable to lift their leg that was hanging over the bed. S1 lifted R1’s legs and placed them in the bed. LPA observed 2 people were required to assist R1 into position. LPA Luong interviewed S1 who stated there are two staff in the evening and overnight which is enough because the residents don’t need that much around those times. S1 also stated that some residents like R1 need more assistance than others. Administrator stated during the day there is an additional staff present.

LPA Olson reviewed MD’s Home Health Certification and Plan of Care dated 02/07/2022; which stated, “Client has been receiving home health services after a fall/left total hip repair that resulted in weakness further complicated by anemia and UTIs in rehab. Client had limited improvement, possibly due to repeated UTIs in (R1’s) Board and Care Facility. Client now has a Foley due to a urinary obstruction/retention, and sees urologist…Client has recently developed pressure sores to bilateral heels, sides of feet, and sacrum. Each visit nurse works to educate client and all staff that client feet must be floated or in Posey Boots at all times…”. A nurse who visits R1 was interviewed, and they indicated R1 had multiple UTIs prior to moving into the facility. LPA interviewed staff about what care they provide R1 related to the catheter and toileting assistance. Staff indicated they changed R1 every two hours and would clean the catheter area with the wipe the doctor provided. LPA interviewed R1's nurse who stated they would take urine samples frequently and notes stated that the nurse would have to inform staff about proper catheter care because R1’s urine was always dark and smelly they felt they didn’t properly care for it.

LPA observed an adequate amount of food at the facility. LPA interviewed staff about R1’s eating habits and weight.
Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20220124095425

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: VILLA GARDENS	FACILITY NUMBER: 425802121
	VISIT DATE: 01/12/2023

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

Staff stated resident was a very picky eater and didn't like meat so only wanted to eat 2 eggs and toast with peanut butter for breakfast lunch and dinner. LPA asked for R1’s weight records, but the facility did not keep track of this and stated R1 couldn't stand and wouldn't be able to weigh them. LPA Olson interviewed R1's nurse who stated the facility tried but would always serve Filipino food and R1 would state that they are tired of it and would rather not eat it. Based on the information obtained, the allegation: Staff are not able to meet the needs of residents is substantiated at this time.

On the allegation: Resident sustained pressure injuries while in care. Reporting party stated that Resident 1 (R1) has 2 open pressure injuries that are stage 2 or higher and has one pressure injury on the left heal and left middle toe as well as 3-4 closed purple pressure injuries on the right heel. Interview with Administrator revealed that R1 was admitted with one stage 1 pressure injury and it may have become a stage 2. LPA reviewed R1’s Physician’s Report dated 11/18/2021. Under section 13. Physical Health Status. History of Skin Condition or Breakdown, Yes was checked “Redness to coccyx=Turn/ Repositioning, air mattress and monitoring only at facility.

LPA Olson reviewed Home Health notes for Resident 1. Home health notes state that:
On 12/22/21 there was one Unstageable: deep tissue Injury on the Left Heel.
On 1/5/22 notes indicated there were “5 new areas identified…RN reviewed need to frequently reposition, use Posey boot to both feet at all times as slippers appear to be too tight for pt and rubbing.”
On 1/14/22 there was one unhealed pressure injury, Stage 2 and four Unstageable: Deep tissue injury.
On 1/18/22 “one of [caregivers], [Staff 2] expressed to nurse that “It is just too much, [R1] doesn’t help, I can’t do it.” Client has been declining in last few weeks, increasing in the speed of decline.”
On 1/25/22 Nurse called PCP office to request order of SNF for client. Client stated they do not want to go anywhere else, that “I can be cared for here the same as someplace else.” Nurse reminded R1 that they had gotten worse since they moved into the facility but R1 said ‘I don’t want to go somewhere else’”.
On 2/19/22 notes stated facility appears to be doing a better job and keeping R1’s feet in Posey boots and off surface to bed.
On 3/7/22 notes stated wound to top of foot appears worse today…“If not improved they will take client to be eval at Urgent Care.”
On 3/14/22 notes stated the left top of foot stated Pressure Ulcer Stage: Stage 3

Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20220124095425

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: VILLA GARDENS	FACILITY NUMBER: 425802121
	VISIT DATE: 01/12/2023

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 3/16/22 notes stated when dressing removed from L foot it was noted (R1) great toe was now purple and entire area around it was reddened/purple, edematous, and draining serous fluid. Area too top of foot also more reddened and swollen. Nurse informed CF and client that client needed to go now to ER—that the only chance (R1) toe could be saved was medical attention and possibly IV antibiotics.

Based on the information obtained, the facility retained R1 with a Stage 3 pressure injury and Unstageable deep tissue injuries, which are prohibited health conditions. Therefore the allegation is Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

An exit interview was conducted, a copy of the report and appeal rights were emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20220124095425

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: VILLA GARDENS	FACILITY NUMBER: 425802121
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 01/13/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ...elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency...	1 2 3 4 5 6 7	Administrator agreed to submit a plan to ensure residents will receive proper care and supervision and services that meet their individual needs by staff that are sufficient in numbers, qualifications, and competency and submit the plan to CCL by 01/13/2023
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when staff did not provide proper care and meet residents needs, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Request Denied Type A 01/13/2023 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615(a)(1) Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.	1 2 3 4 5 6 7	Administrator agreed to submit a statement of understanding of regulation 87615 and a plan on what to do if a resident develops a prohibited health condition and submit it to CCL by 01/13/2023.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when they retained a resident with prohibited health conditions, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5