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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 07/11/2022
Date Signed: 07/11/2022 02:05:34 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
09/09/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210909131131
FACILITY NAME:SANTA MARIA TERRACEFACILITY NUMBER:
425850025
ADMINISTRATOR:ENRIQUEZ, SANJUANAFACILITY TYPE:
740
ADDRESS:1405 E MAIN STTELEPHONE:
(805) 925-8713
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:140CENSUS: 97DATE:
07/11/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Amy Bowman, Wellness DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff not maintaining residents hygiene.
Staff not providing assistance to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA Diaz conducted the initial investigation, reviewed facility documents and conducted interviews with staff and residents. LPA Diaz interviewed clients on 09/27/21, 9/30/21, and 10/5/21. LPA Diaz interviewed staff on 9/15/21, 9/27/21, 9/28/21, 10/5/21, and 10/6/21. LPA Olson requested and reviewed R1’s admission agreement, physician’s report, preadmission appraisal, assessment, care plan, July and August 2021 Shower Schedule, and ledgers provided. LPA Olson reviewed records, interviewed staff on 5/16/22. LPA Olson interviewed staff and residents on 5/22/22 and 6/6/22.

On the allegation: Staff not maintaining residents hygiene. Reporting party stated that R1 was not showered for a month. LPA interviewed staff which revealed that R1 would refuse showers a lot but once a shower chair was provided by the family, they refused less. Family interviews revealed that the facility didn’t ask for a shower chair until 2-3 weeks after admission and after R1 refused showers.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
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 5
Control Number 29-AS-20210909131131
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: SANTA MARIA TERRACE
FACILITY NUMBER: 425850025
VISIT DATE: 07/11/2022
NARRATIVE
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After they provided a shower chair, the facility said that they had an extra one that was already provided. LPA Olson reviewed R1’s Resident Appraisal and Needs and Services Plan which state that R1 would receive showers twice a week. LPA reviewed July 2021 shower schedule which indicated that R1 refused a shower 7/6/21 and 7/22/21 and was only showered once on 7/27/21 since moving in on 7/5/21. LPA interviewed the Wellness Director at the time who stated they showered Resident 1 at least once in July but didn’t track it. Per the needs and services plan, the resident was not showered twice a week to meet their needs. Based on LPA interviews and record review the allegation is deemed Substantiated at this time.

On the allegation: Staff not providing assistance to residents. Reporting Party (RP) stated that R1 would use the provided pendant to call for assistance. RP provided an example that R1 would use their pennant to call staff while on the toilet, yet staff wouldn’t respond. RP stated that family would have to call the facility directly, and receptionists would page care staff to go and assist R1. LPA interviewed 2 Facility Receptionists who confirmed that family’s and residents call the front desk often to ask for care staff to be paged for assistance due to staff not responding to their pennant timely. Staff interviews confirmed they are paged multiple times per shift by the receptionist to assist residents. LPA reviewed call logs from 7/13/21-7/16/21 and 8/3/21-8/6/21 which revealed R1 pressed their pendant a total of 60 times. 24/60 (40%) of R1’s calls were answered in 15 minutes or less, which all staff confirmed is the facility’s goal response time. 12/60 (20%) of R1’s calls were answered within 16-29 minutes, 4/60 (6.6%) of calls were answered within 30-45 minutes, and 20/60 (33.3%) of R1’s calls were not answered at all (remained unanswered). Based on staff and resident interviews, most felt there was not enough staff to meet the resident’s needs and respond timely to the call buttons. Based on LPA interviews and record review the allegation is deemed Substantiated at this time.

Exit interview, report given, deficiencies cited on 9099-D, Civil Penalty of $250 is assessed for repeating the same violation within 12 months, appeal rights given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20210909131131
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: SANTA MARIA TERRACE
FACILITY NUMBER: 425850025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2022
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements- Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met as evidenced by:
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Administrator agreed to submit updated staffing schedule showing an adequate amount of staff to meet residents needs and respond to call buttons timely.
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Based on interviews and record review, the licensee did not ensure there was sufficient staff to meet resident needs which posed an immediate health and safety risk to clients in care
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Type B
07/15/2022
Section Cited
CCR
87464(d)
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87464(d) Basic Services. …If a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal...either directly or through outside resources.
This requirement is not met as evidenced by:
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Administrator agreed to implement a plan to document shower refusals and to ensure residents receive the proper number of showers per week.
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Based on interviews and record review, the licensee did not comply with the above cited section when R1 did not receive a shower for 22 days after moving into the facility, which posed a potential health and safety risk to residents in care.
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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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/09/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210909131131

FACILITY NAME:SANTA MARIA TERRACEFACILITY NUMBER:
425850025
ADMINISTRATOR:ENRIQUEZ, SANJUANAFACILITY TYPE:
740
ADDRESS:1405 E MAIN STTELEPHONE:
(805) 925-8713
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:140CENSUS: 97DATE:
07/11/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Amy Bowman, Wellness DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
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9
Staff not providing assistance to resident resulting in fall.
INVESTIGATION FINDINGS:
1
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Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA Diaz conducted the initial investigation, reviewed facility documents and conducted interviews with staff and residents. LPA Diaz interviewed clients on 09/27/21, 9/30/21, and 10/5/21. LPA Diaz interviewed staff on 9/15/21, 9/27/21, 9/28/21, 10/5/21, and 10/6/21. LPA Olson requested and reviewed R1’s admission agreement, physician’s report, preadmission appraisal, assessment, care plan, July and August 2021 Shower Schedule, and ledgers provided. LPA Olson reviewed records, interviewed staff on 5/16/22. LPA Olson interviewed staff and residents on 5/22/22 and 6/6/22.

On the allegation: Staff not providing assistance to resident resulting in fall. According to the Reporting Party (RP) Resident 1 (R1) fell multiple times in care and did not receive assistance from staff. R1 went to the hospital on 8/5/21 and the hospital doctor refused to send R1 back to the facility because R1 was not getting the right care there.
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20210909131131
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: SANTA MARIA TERRACE
FACILITY NUMBER: 425850025
VISIT DATE: 07/11/2022
NARRATIVE
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RP stated that maybe R1 needed more care but the facility never informed them. RP stated they had to call the facility for updates and ask what was going on. R1’s physician’s report dated 7/1/21 indicates a diagnosis of hypertension, hypercholesteremia, mild cognitive impairment, needs assistance with bathing, needs minimal assistance with dressing/grooming. R1’s Resident Appraisal dated 7/6/21 indicates R1 uses a walker, needs stand by assistance for transfers for safety, needs stand by assistance for transferring to the toilet, needs physical assistance with bathing twice a week, needs stand by assistance with dressing and needs clothing set up, and needs frequent checks to ensure safety. All staff interviewed stated they try to provide assistance to residents as quickly as possible and respond to call buttons as quickly as possible. Most residents interviewed stated staff provided assistance to meet their needs. A care note for R1 from 7/15/21 at 5:40am indicates a med tech responded to R1’s call and was observed sitting on the bathroom floor with no visible injuries, but was confused, so staff called 9-1-1. The resident left the hospital in stable condition with no injuries but some confusion. An Incident Report indicates on 8/5/21 at 11:45pm, R1 was observed on the floor by staff during a check. R1 complained of back pain and 9-1-1 was called for medical attention. The facility was unable to provide detailed care notes for R1 showing that frequent checks were completed. The electronic system staff use to track resident needs and the care provided only prompts once per shift, and not multiple times per shift; therefore there are no records showing how often each care task was performed. Based on the evidence obtained, there was insufficient evidence to substantiate the allegation that a lack of assistance resulted in a fall. Therefore the allegation is deemed unsubstantiated at this time. An Advisory Note for Technical Assistance was issued to recommend implementing a system that has more accurate data for tracking care completed.

Exit interview, Technical Assistance issued, report emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5