425850229-11-16-2022-29-AS-KBUY-CLFR9N-20221123114945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850229
Report Date: 11/16/2022
Date Signed: 11/16/2022 06:47:38 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
06/03/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20220603151229

FACILITY NAME:	A CASA TUNNELL		FACILITY NUMBER:	425850229
ADMINISTRATOR:	SORIANO, APRILYN A		FACILITY TYPE:	740
ADDRESS:	958 E TUNNELL STREET		TELEPHONE:	(805) 922-7670
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS: 5	DATE:	11/16/2022
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Aprilyn Soriano, Administrator/Licensee		TIME COMPLETED:	06:50 PM

ALLEGATION(S):

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Facility retained a resident with a prohibited health condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial complaint visit was conducted on 06/09/2022 by LPA Jeannette Olson. During today’s visit, LPA met with Administrator/Licensee and explained the reason for the visit.

On 06/03/2022, the Department received a complaint regarding an allegation that the facility retained a resident with a prohibited health condition. It was alleged that while under facility care, Resident #1 (R1) developed a stage 4 pressure injury and was not on hospice.

On 06/09/2022, between 11:00am and 2:30pm, LPA Olson conducted the initial 10-day complaint visit.
The LPA met with Aprilyn Soriano, Administrator/Licensee, and explained the purpose of the visit.
LPA toured the facility and interviewed staff. The LPA obtained documents related to R1 and noted further investigation was needed.
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: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

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 6

Control Number 29-AS-20220603151229

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 TUNNELL	FACILITY NUMBER: 425850229
	VISIT DATE: 11/16/2022

NARRATIVE

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LPA Olson conducted interviews on 06/09/2022 with the Administrator, staff #1 (S1), and Witness #1 (W1); on 06/21/2022, at approximately 11:30am, with Long Term Care Ombudsman (LTCO); and on 06/25/2022, at approximately 1:00pm, with R1’s resident representatives. Additionally, the LPA reviewed copies of Marian Regional Medical Center medical records, Dignity Home Health records, facility records including documents related to R1, and photographs of R1’s pressure injuries.

The information obtained from interviews revealed that LTCO visits the facility once a month and would visit R1 every time. The LTCO noted that R1 would usually talk to them but the last 3 months from March 2022 to May 2022, R1 would not wake up or acknowledge LTCO when they walked in. The LTCO observed R1 to always be in bed sleeping, lying on back. The LTCO reported the concerns of R1’s decline to the administrator who stated they were aware and had been trying to get a doctor appointment for R1, but the doctor was on leave, and they was trying to find another doctor.

The investigation revealed that on 12/15/2020, R1 was admitted to the facility under the prior facility ownership. The facility had a change of ownership effective 01/12/2022, and the current licensee /administrator, Aprilyn Soriano, became the new facility owner. Documents reviewed revealed that R1 had a history of skin breakdown and was treated by home health for wound care during various times while residing at the facility.

The home health records reviewed dated 04/05/2022 through 05/27/2022, revealed that R1 was being treated twice per week for multiple pressure injuries. On various dates, the home health nurse documented R1’s pressure injuries as stage 1 and stage 2. During the visits to perform wound care, the nurse stressed the importance of continued pressure relieving measures and good nutrition and hygiene to promote healing, and when to seek medical attention if symptoms worsened.

A review of the home health clinical notes for the month of May 2022 revealed that on 05/03/2022, the home health nurse performed wound care. Upon assessment of the wound, the nurse noted R1’s depends were soiled with urine. The nurse assisted with the caregiver to clean R1 and change R1’s depends. The caregiver assisted with repositioning R1 and the nurse stressed the importance of good nutrition, of increased protein, vitamin C and fluids to promote optimal wound healing as well as pressure relieving measures.
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: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20220603151229

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 TUNNELL	FACILITY NUMBER: 425850229
	VISIT DATE: 11/16/2022

NARRATIVE

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On 05/06/2022, the nurse documented that R1’s right buttock and coccyx wounds were now connecting making a larger wound, wound drainage is serous and moderate, no signs or symptoms of infection noted at that time. A wound consult was requested for concerns the wounds were slow to heal. The administrator informed the nurse that R1 was up all night talking and did not get much sleep. The nurse reviewed the plan of care with the administrator and stressed the importance of pressure relieving measures.

On 05/10/2022, upon arrival for wound care, the nurse noted that R1 had soiled depends with urine and bowel movement. The nurse assisted the caregiver to clean R1 and change R1’s depends. The nurse noted the wound to right buttock and coccyx was not healing well, and may need a wound consult due to eschar and slough. The nurse sent a photo of the wound to the wound care specialist and received recommendations for conservative sharp debridement. The new wound care plans were reviewed with the caregiver and stressed the importance of repositioning at least every 2 hours and the importance of good hygiene. R1’s primary physician, Dr. Gonzales was also contacted to approve the wound care specialist orders.

On 05/13/2022, the nurse noted wound to coccyx and right buttock not healing well, noted increase of moderate drainage to large serous drainage and noted odor to wound. R1 had increased pain. The nurse noted old wound to right hip had re-opened and photos were taken of wounds. The nurse reviewed the plan of care with the administrator and stressed the importance of pressure relieving measures and to seek urgent medical attention if worsening of symptoms or has life threatening symptoms. The home health nurse contacted Dr. Gonzales to report worsening of wound and possible concerns of infection and requested for a possible antibiotic. Dr. Gonzales was also notified of R1’s decline per the administrator, as R1 was not eating well, up all night, and sleeping during the day.

On 05/17/2022, home health notes indicate R1’s sacrum/coccyx wound not healing, increased eschar to 90% and wound connected to right buttock wound, measured in one, all wounds measured, and photo taken. R1 was prescribed an antibiotic Cephalexin 500 mg one (1) tab four (4) times per day for seven (7) days. The nurse instructed caregiver in pressure relief in position changes, increase protein intake, adequate fluids and nutrition, keep depends dry and clean, and reviewed patient safety, caregiver verbalized understanding.

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: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20220603151229

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 TUNNELL	FACILITY NUMBER: 425850229
	VISIT DATE: 11/16/2022

NARRATIVE

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On 05/20/2022, the nurse documented that R1 received a supine position hospital bed. The administrator informed the nurse that R1 was eating very small meals over the last week, taking sips of fluids. The nurse noted the sacrum/coccyx wound not healing and connected to buttock wound, large amount eschar 90%. The nurse instructed the administrator to offer frequent fluids, protein, keep R1 frequently repositioned, clean and dry.

On 05/24/2022, the home health nurse documented a visit to the facility for R1’s wound care and noted the pressure ulcer to R1’s sacrum/coccyx was a stage 2 and not healing. The wound measured at 10.5cm in length by 10cm in width by 0.4cm in depth. The wound tissue observed slough at 10% and eschar at 90%. The pressure injury to right buttock was a stage 2 healing by secondary intent also measured at 10.5cm in length by 10cm in width by 0.4cm in depth. The wound tissue observed slough at 10% and eschar at 90%. The pressure injury to R1’s left hip was a stage 2 healing by secondary intent. The wound measured at 4.5cm in length by 3cm in width by 0.1cm in depth. The wound tissue observed to be pink, beefy red. The nurse instructed the staff in infection control, signs and symptoms of infection, and when to call for immediate medical attention.

On 05/27/2022, the home health nursing notes documented: “Management Aprilyn (administrator Soriano) refused the skilled nursing visit and stated they were now with a different home health agency and requested to be discharged from the agency”. On the same day, R1 was seen by a nurse practitioner and a physical exam was completed. The physician’s report dated 05/27/2022, listed R1’s diagnoses as congestive heart failure, aortic stenosis, atrial fibrillation, benign prostatic hyperplasia, anemia, and decubitus (pressure injury) stage 3-4 to buttocks. The report also lists conditions of dementia, blind, history of skin breakdown, functional quadriplegia, no capacity for self-care, and physical health status poor. The comments noted that R1 is bed bound and has not eaten in over 3 weeks, only liquids including Glucerna. R1 has just completed antibiotics for the decubitus (pressure injury). R1 appeared to be at end stage of life and a hospice referral was made. Facility progress notes document that on 05/27/2022, the administrator contacted R1’s resident representative to get approval for the hospice services. R1’s resident representative refused hospice services and insisted R1 be taken to the emergency room.

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: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20220603151229

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 TUNNELL	FACILITY NUMBER: 425850229
	VISIT DATE: 11/16/2022

NARRATIVE

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On 05/28/2022, R1 was admitted to the Marian Regional Medical Center. The hospital records indicated that in the emergency room, R1 was noted to have a large very malodorous ulceration in the sacral area which appeared to have deeper tunneling. “The patient is completely obtunded, tachycardic, hyponatremic. It appears the patient is not feeding self or participating in any activities of daily living. Patient is very ill at the time of presentation, septic and probably with a stage IV decubitus ulceration which was infected.”

Based on records review and interviews, the Department has sufficient evidence to support the allegation “Facility retained a resident with a prohibited health condition”, therefore the allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D)
Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20220603151229

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 TUNNELL	FACILITY NUMBER: 425850229
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/17/2022 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615(a)(1) Prohibited Health Conditions (a) Persons who ...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. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a memo of understanding regarding Regulation 87615 Prohibited Health Conditions to CCL by 11/17/22
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above when R1 (not on hospice) was diagnosed on 05/28/2022 with infected stage 4 pressure injuries, which posed an immediate 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: 11/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022

LIC9099 (FAS) - (06/04)

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