425850025-2-2-2024-29-AS-KBUY-D2UUMX-20240227144304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 02/02/2024
Date Signed: 02/02/2024 04:29:07 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
10/20/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20231020141823

FACILITY NAME:	SANTA MARIA TERRACE		FACILITY NUMBER:	425850025
ADMINISTRATOR:	ENRIQUEZ, SANJUANA		FACILITY TYPE:	740
ADDRESS:	1405 E MAIN ST		TELEPHONE:	(805) 925-8713
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	140	CENSUS: 95	DATE:	02/02/2024
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Vanessa Vazquez, Wellness Coordinator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff mismanaged resident medication
Facility does not have adequate staff to meet residents needs
Facility did not follow admissions agreement
Facility is not kept clean

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA interviewed reporting party on10/23/23, interviewed Wellness Director and Care Staff on 10/25/23, 11/27/23, 12/15/23 and 2/2/24 and requested relevant documents. LPA met with Administrator and Wellness Coordinator over the phone and explained the purpose of the visit.

On the allegation: Staff mismanaged resident medication. It was alleged that Resident 1 (R1) received three times the amount of medication Warfarin that the doctor ordered. It was alleged that R1’s blood clotting International Normalized Ratio (INR) reading was 8 when the normal is between 2 and 3. LPA received a call from the Wellness Director who informed LPA of the medication error. On 10/25/23 LPA interviewed staff that stated they did not read the label for the medication. They provided R1 the medication the day before and it was a 1mg tablet, and assumed the medication was the same, when in fact the medication had changed to a 3mg tablet. The physician’s order indicated to give 1.5 tablets of the 1mg tablet, and the med tech gave 1.5 tablets of the 3mg tablet. 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: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

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-20231020141823

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: 02/02/2024

NARRATIVE

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Staff stated they know they should have checked the bottle and will read the label and not assume again. The resident’s physician was contacted and the resident was immediately placed on additional wellness checks. Wellness Director stated the staff was retrained and written up for the medication error. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Facility does not have adequate staff to meet residents needs. It was alleged that due to there being only one Med Tech for around 100 residents, they are too rushed due to providing so many medications to so many residents. It was also alleged that there are not enough staff to adequately meet residents needs and Resident 1 and Resident 2 (R1 and R2) were so neglected that they decided to hire private caregivers. It was also alleged R2 fell, was bleeding from their lip and no caregiver noticed it. Reporting party stated R2 has dementia and is on the highest level of care but staff are too busy to check on R2. LPA interviewed Staff and Residents. Most staff and residents stated the facility is under staffed. There are usually 2 staff scheduled, sometimes 3. Staff and residents stated sometimes staff call out and one caregiver has to cover all four floors and 90-100 residents by themselves. Staff and residents also stated they thought one med tech was not enough to meet all the medication needs of residents. Interviews with staff on 12/15/23 stated staffing has gotten better and now they are only left alone around once per week, not two or three times as was previously. Staff also stated they check on R1 and R2 multiple times a day in the AM and PM when they do not have their private caregiver. Administrator and Wellness Director stated when they discovered R1 and R2 hired private caregivers they tried to hold a meeting but family never wanted to meet. Administrator stated one medtech is enough because not every resident is on Medication Assistance. When asked about staffing Wellness Director stated they have two staff scheduled in the AM and PM and caregiver come mid shift if needed. LPA observed staff schedules from October through December 2023. LPA observed 2-3 caregivers and one med tech scheduled each shift. Administrator stated if there are any call outs Wellness Director or Wellness Coordinator come in and help cover. Based on the information obtained, the allegation is deemed Substantiated at this time due to multiple staff stating they are left alone to escort, respond to pendants, deliver food for almost 100 residents at least once per week.

On the allegation: Facility did not follow admissions agreement. It was alleged that residents are not receiving housekeeping, there are often diapers on the floor and beds aren’t made. It was also alleged residents’ teeth aren’t being brushed, dressing assistance isn't being provided, and showers aren’t given per the Admission agreement. LPA interviewed staff and residents. Interviews revealed housekeeping comes and deep cleans once a week, and certain residents get daily housekeeping for an extra fee.
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: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20231020141823

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: 02/02/2024

NARRATIVE

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Staff and Residents stated housekeeping isn’t perfect but if a caregiver observes a dirty room they will call housekeeping to come clean it and they usually do. Staff interviewed stated there are some days (usually weekends) when there is only one housekeeper and they can’t clean everything so the caregivers have to. LPA interviewed Residents and Staff about grooming assistance. Staff stated they brush residents teeth daily and help get them up and dressed if needed per their care plan. When asked about showers staff state if a staff calls off, showers don’t get done and if someone refuses a shower they let the Med tech know and they try. LPA interviewed Med tech on 11/27/23, who stated today a resident refused a shower, they tried to shower them and they refused and was going to let the Wellness Director know. LPA asked if they inform the Medtech coming on (the following shift) that it was missed and Medtech said no, it’s the caregivers responsibility. LPA spoke to this resident who stated they did not refuse a shower they just didn’t want their feet to get wet. LPA asked if staff offered ideas on how to shower them without getting their feet wet and they stated no, that is their job to figure out. LPA informed the Wellness Director who stated they had already planned an in-service training on showers and will train staff to ask questions and overcome simple obstacles. Resident’s interviewed had mixed opinions on receiving their proper care and showers per admission agreement. Incontinent residents stated they don’t believe they are checked on every two hours. Residents stated they may be checked on 3-4 times throughout the day. Staff interviewed stated they try to complete everything on their Plan of Care (POC) but it’s hard to do everything with only 2 staff and they can’t be everywhere at once. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Facility is not kept clean. It was alleged that the dining room tablecloths are stained and dirty, not clean. LPA observed the dining room and tablecloths on 10/15/23 after breakfast, before lunch service. LPA observed four tablecloths to be dirty and stained. Staff interviews revealed they change tablecloths after lunch, before dinner and use a linen company. Staff stated the linen company sometimes send tablecloths with stains, and they have no choice but to use them. LPA recommended to staff to try and ask the company to not send dirty tablecloths or switch to a different color (other then white). On 12/15/23 LPA observed no dirty tablecloths. Based on the information obtained, the allegation is deemed Substantiated at this time. A technical Violation was issued.

A civil penalty for a repeat violation for $250 was assessed.
An exit interview was conducted, a copy of the report, Civil Penalty, and appeal rights were issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20231020141823

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: 02/02/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/03/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Wellness Director held in service trainings with all med techs on the importance of the 7 medication rights. POC cleared during the visit.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply in the section sited above when staff did not properly assist resident with medications and issued the incorrect dose which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 02/09/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) 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:	1 2 3 4 5 6 7	Licensee shall submit a staffing plan showing adequate amount of staff to meet resident needs, including no less than two dedicated care staff on shift on all times.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply in the section sited above when staff were not sufficient in numbers at all times to meet resident needs, which posed a potential 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: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20231020141823

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: 02/02/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/02/2024 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	87464 Basic Services (f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing.... This requirement was not met	1 2 3 4 5 6 7	Facility implemented a new shower log to better track missed showers. POC is was cleared at the time of the visit.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply in the section sited above when staff did not properly assist residents with showers or have a system to make up missed showers 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
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

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