425850025-9-30-2021-29-AS-KBUY-C7GNFA-20211004102513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 09/30/2021
Date Signed: 09/30/2021 05:31:55 PM

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
07/30/2020 and conducted by Evaluator Arien Diaz

COMPLAINT CONTROL NUMBER: 29-AS-20200730152731

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: 81	DATE:	09/30/2021
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Joanna Enriquez		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff administered another resident's medications to resident.

INVESTIGATION FINDINGS:

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LPA Diaz reviewed facility documents and conducted interviews with staff and residents. LPA interviewed staff on 08/07/2020, at 2:22pm and on 09/11/2020 at 11:19am and 3:09pm. LPA interviewed staff on 10/15/2020, at 4:06pm and on 10/23/2020, at 3:50pm and at 4:21pm. LPA interviewed staff on 10/27/2020, at 4:32pm, 4:56pm, and on 10/29/2020, at 11:39pm. LPA interviewed residents on 09/10/2020, at 3:30pm, 3:55pm, 4:16pm and on 10/21/2020 at 11:40am, 11:51am, 12:18pm, 12:21pm, 12:40pm, and 12:51pm. LPA interviewed complainants on 10/15/220 at 3:39pm and on 10/28/2020, at 9:10am. On the allegation: Staff administered another resident's medications to resident: LPA Diaz interviewed staff regarding this allegation. The Administrator and Wellness Director admitted fault regarding the med error involving (R1) on 5/16/2020. Based on the interviews, the allegation for Staff administered another resident's medications to resident is deemed substantiated at this time.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

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 7

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
07/30/2020 and conducted by Evaluator Arien Diaz

COMPLAINT CONTROL NUMBER: 29-AS-20200730152731

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: 81	DATE:	09/30/2021
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Joanna Enriquez		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff not providing adequate supervision.
Resident is not receiving assistance with showers as needed.
Facility does not provide food of the quality or quantity to meet the needs of the resident.
Resident does not have functioning pendant to alert staff.
Facility did not provide linens for resident's bed.
Facility is not providing adequate housekeeping services.
Facility is charging resident for services resident did not receive.

INVESTIGATION FINDINGS:

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LPA Diaz reviewed facility documents and conducted interviews with staff and residents. LPA interviewed staff on 08/07/2020, at 2:22pm and on 09/11/2020 at 11:19am and 3:09pm. LPA interviewed staff on 10/15/2020, at 4:06pm and on 10/23/2020, at 3:50pm and at 4:21pm. LPA interviewed staff on 10/27/2020, at 4:32pm, 4:56pm, and on 10/29/2020, at 11:39pm. LPA interviewed residents on 09/10/2020, at 3:30pm, 3:55pm, 4:16pm and on 10/21/2020 at 11:40am, 11:51am, 12:18pm, 12:21pm, 12:40pm, and 12:51pm. LPA interviewed complainants on 10/15/220 at 3:39pm and on 10/28/2020, at 9:10am.

On the allegation: Staff not providing adequate supervision: LPA Diaz interviewed both staff and residents regarding this allegation. 8 of 8 staff interviewed stated consistent procedures to ensure that residents are frequently checked on. Staff members interviewed stated that residents are checked on every 2-3 hours if not more.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

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

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 29-AS-20200730152731

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: 09/30/2021

NARRATIVE

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Three staff members interviewed also stated there are backup MedTech’s or Caregivers to provide additional support. Administrator can hear all communication among staff from their walkie talkie. 9 of 9 residents stated that the staff consistently checks on them. LPA reviewed the facility’s frequent checklist, and R1 was regularly checked on and documented by staff. Therefore, based on the interviews, and record reviewed the allegation for lack of supervision resulting in resident sustaining multiple falls is deemed unsubstantiated at this time.

On the allegation: Resident is not receiving assistance with showers as needed: LPA Diaz interviewed both staff and residents regarding this allegation. All staff consistently stated procedures and experiences when showering residents. All staff stated they follow the shower schedule and have never forgotten to shower a resident. All staff members stated that they document the shower log if residents refuse to shower, therefore the next shift will be aware of residents that need showers. All staff members stated that they are unaware of any showering issues among the residents. The Administrator stated, there have not been any issues with showers, and nothing has been escalated regarding showers. The Administrator is involved and can hear all communication among staff from their walkie talkie. The administrator confirmed that the staff have been good about giving consistent showers with no issues. Incontinent residents stated they are content with the shower assistance and do not have any issues. R1 stated that their shower times are Tuesday and Friday, and shower assistant in the facility is fine. LPA reviewed the facility’s shower log and it confirms R1’s statement. Based on the interviews and records reviewed, the allegation that the Resident is not receiving assistance with showers as needed is deemed unsubstantiated at this time.

On the allegation: Facility does not provide food of the quality or quantity to meet the needs of the resident: Staff#1, (S1) explained that meals are served one floor at a time to ensure that meals are served hot. All staff interviewed stated that the facility provides good quality food. The food is warm and delivered immediately. Staff stated, some residents do not eat their food right away and then their food gets cold. The kitchen always provides vegetables, meat, bread and some type of side. All staff interviews confirm that meals are served warm. (S2) stated that the Food Service Director, and R1’s family had a discussion and created a special meal plan for R1. R1 would still reject food from the meal plan and then the facility would bring R1 an additional alternative meal at no cost. 2 of 9 residents interviewed stated the food is not served warm and the food is too dry or too tough to chew.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 29-AS-20200730152731

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: 09/30/2021

NARRATIVE

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7 of 9 residents stated that the there is a substantial amount of food served among meals, the quality of food is good, and the food is served warm. 2 residents interviewed stated they have too much to eat and make two meals out of one. LPA observed two residents’ lunches, and both lunches were of good quality and quantity. LPA also observed a plate of food being prepared in the kitchen. The plate was a substantial size and of good quality. LPA observed fresh fruits and vegetables inside the kitchen freezer. Based on the interviews and observations, the allegation Facility does not provide food of the quality or quantity to meet the needs of the resident is deemed unsubstantiated at this time.

On the allegation: Resident does not have functioning pendant to alert staff: LPA Diaz interviewed both staff and residents regarding this allegation. LPA had (S1) press a resident’s emergency button as a test, and a different staff member responded to the call in 2 minutes. (S1) stated that the call buttons are never taken away from residents. LPA then interviewed residents and verified that 9 of 9 residents stated that their call buttons always work, and staff responds right away, but sometimes are delayed if other residents are being helped. 3 of 9 residents stated that staff responds quickly to their call buttons within 10 minutes or less. Staff members interviewed stated the response time to assist a resident is within 5 min or less. 4 of 9 staff interviewed stated they have experienced issues clearing the staff pendant, but never experienced malfunctions with residents call button. Issues clearing pendants were escalated to the administrator and fixed the same day. (S2) stated that Informational Technology will be upgrading the facility call system by December 1st, 2020. Based on the interviews and observation, the allegation Resident does not have functioning pendant to alert staff is deemed unsubstantiated at this time.

On the allegation: Facility did not provide linens for resident's bed: LPA Diaz interviewed both staff and residents regarding this allegation. (S2) stated that all residents are to bring their own bed linens during the initial entry, but if residents neglect to bring their own linens, the facility will provide the resident with linens. Housekeeping and staff interviewed stated that the resident’s sheets are changed daily, and if sheets become dirty, they are changed with extra sheets that are stored in the resident’s closet. Housekeeping interviewed stated that R1’s sheets are generally changed in the morning and that R1’s sheets are never wet or dirty.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 29-AS-20200730152731

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: 09/30/2021

NARRATIVE

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9 of 9 residents interviewed stated that they there are satisfied with linens, the linens are soft and smell good, and confirm that if linens become dirty the staff will change them with spare sheets in the closet. R1 stated that housekeeping is good, R1s sheets are always clean, and they throw away R1s trash every day. Based on the interviews, the allegation Facility did not provide linens for resident's bed is deemed unsubstantiated at this time.

On the allegation: Facility is not providing adequate housekeeping services: According to the facility staff, resident rooms are cleaned at least once a week by housekeeping, and the caregivers will clean rooms as needed. The housekeepers clean the floors, restrooms, and wipe down the furniture. The caregivers will clean up spilled drinks or assist with laundry. Housekeeping stated that R1 was hoarding trash in room. Housekeeping and R1’s family explained to R1 that the trash is old and must be thrown away daily. Housekeeping stated that R1 was cooperative and complied and stated there are no issues cleaning R1’s room. Housekeeping cleans R1’s room once a week and empty’s R1’s trash once or twice a day. 9 of 9 residents interviewed stated that the rooms are cleaned once a week and are satisfied with the cleanliness of the rooms. R1 stated that housekeeping is good, my sheets are always clean, and they throw away my trash every day. Interviews with both residents and staff confirm that resident rooms are regularly cleaned. Based on the interviews, the allegation Facility is not providing adequate housekeeping services is deemed unsubstantiated at this time.

On the allegation: Facility is charging resident for services resident did not receive: LPA Diaz interviewed residents and staff regarding this allegation. Staff members interviewed stated they follow the shower schedule and have never forgotten to shower a resident. All staff members stated if residents refuse to shower, it is documented in the shower log. Then the next shift will review the log and shower residents that have not showered yet. All staff members stated that they are unaware of any showering issues among the residents. Staff stated we have no issues with showers, and nothing has been escalated to supervisors about showers. Administrator can hear all communication among staff from their walkie talkie and confirmed that the staff have been good about giving consistent showers with no issues. Housekeeping and staff interviewed stated that the resident’s sheets are changed daily, and if sheets become dirty, they are replaced with clean sheets stored in the resident’s closet. Housekeeping stated that R1’s sheets are generally changed in the morning and that R1’s sheets are never wet or dirty. Housekeeping cleans R1’s room once a week and empties R1’s trash once or twice a day.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 29-AS-20200730152731

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: 09/30/2021

NARRATIVE

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9 of 9 residents interviewed stated that they there are satisfied with linens, the linens are soft and smell good, and confirm that if their linens get dirty, then the staff will change them with spare sheets in the closet. Incontinent residents confirmed and stated they are content with the shower assistance in the facility and do not have any issues with showering. R1 stated that their shower times were Tuesday and Friday mornings and shower assistant in the facility is fine. R1 confirmed and stated that housekeeping is good, sheets are always clean, and trash is thrown away every day. Interviews with both residents and staff confirm that resident rooms are regularly cleaned. LPA reviewed R1s admission agreement and the services have been provided by the facility. Based on the interviews, the allegation Facility is charging resident for services resident did not receive deemed unsubstantiated at this time.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 29-AS-20200730152731

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: 09/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/04/2021 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall ensure that all Medication technicians will attend Inservice training. Licensee shall submit a written plan to CCLD by the due date that states how Licensee plans to ensure that the same error is avoided in the future.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not ensure that resident received the prescribed medication	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: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

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