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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850229
Report Date: 11/16/2022
Date Signed: 11/16/2022 06:37:44 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
06/20/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220620111537
FACILITY NAME:A CASA TUNNELLFACILITY NUMBER:
425850229
ADMINISTRATOR:SORIANO, APRILYN AFACILITY TYPE:
740
ADDRESS:958 E TUNNELL STREETTELEPHONE:
(805) 922-7670
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 5DATE:
11/16/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Aprilyn Soriano, Administrator/LicenseeTIME COMPLETED:
06:45 PM
ALLEGATION(S):
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Staff neglected Resident #1 (R1) resulting in R1 developing stage 4 pressure injuries.
Facility staff failed to seek medical attention in a timely manner for Resident #1 (R1) contributing to R1’s stage 4 pressure injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver final findings for the above allegations. The initial complaint visit was conducted on 06/21/2022 by LPA Jeannette Olson. During today’s visit, LPA met with Administrator/Licensee and explained the reason for the visit.

On 06/20/2022, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that Resident #1 (R1) developed a stage 4 sacral pressure injury while in care at the facility and the facility staff failed to seek medical attention in a timely manner for R1, contributing to R1’s stage 4 pressure injuries. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Heidy Bendana.

On 06/21/2022, between 1:00pm 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.
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: 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 7
Control Number 29-AS-20220620111537
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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The LPA advised the Licensee that the complaint has been assigned to an Investigations Branch (IB) Investigator to conduct the investigation. The LPA requested documents pertinent to the investigation.

Investigator Bendana conducted interviews on 07/28/2022 with residents, staff #1 (S1) and administrator; on 08/11/2022 and 08/12/2022 with Dignity Home Health Registered Nurse; on 08/12/2022 with R1’s Nurse Practitioner; on 09/02/2022 with R1’s Primary Care Physician; on 09/08/2022 with R1’s resident representatives; and on 09/09/2022 with Dignity Home Health Physical Therapist. Additionally, Investigator Bendana obtained and reviewed copies of R1’s Marian Regional Medical Center medical records, Dignity Home Health records, photographs of R1’s pressure injuries, death certificate, and facility records including documents relevant to R1.

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 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (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 7
Control Number 29-AS-20220620111537
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 of 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 not healing well, 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (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: 6 of 7
Control Number 29-AS-20220620111537
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 bedbound 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (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 7
Control Number 29-AS-20220620111537
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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This is an amended report. 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.”

After admission, R1 was treated aggressively with IV antibiotics and wound care. R1’s mental status did not improve, and R1 did not show signs of improvement. On 06/01/2022, R1’s resident representative opted to change the focus of R1’s care to comfort and R1 was transitioned to hospice care. By 06/03/2022, R1 was admitted to hospice and by 06/05/2022, R1 passed away. The Santa Barbara County Department of Health Certificate of Death lists the cause of death as Sepsis Proteus, Cellulitis, and Sacral Decubitus Ulcer.

Information obtained through interviews found that the administrator and S1 both stated they were repositioning R1 every hour. However, it is unknown if this was happening as R1’s pressure injuries were progressively getting worse. A review of the facility repositioning logs, initialed by the administrator and staff, for the period of 05/01/2022 through 05/28/2022 at 11am, documented that R1 had been repositioned every hour. However, on a visit on 06/09/2022, LPA Olson reviewed R1’s entire file at the facility and observed repositioning logs for only 05/01/2022 through 05/10/2022 and obtained copies. Licensee later sent in the additional logs on 11/15/2022 that were not presented during the initial visit. Since the repositioning logs provided were only for May 2022, it is unknown if R1 was being repositioned every hour before or after that time period. The facility progress notes reviewed for the months of April and May 2022, initialed by the administrator, indicated that R1 was being repositioned every 2 hours. The interviews also revealed that a baby monitor was being used in R1’s bedroom. S1 stated she “checked” on R1 every 15 minutes. Administrator and S1 both stated they were aware that by May 1, 2022, R1’s wounds were getting worse and R1’s condition was declining. They noticed R1’s wounds getting bigger, noticed drainage, a bad smell and tunneling by 05/17/2022. R1 was complaining of increased pain and refusing to eat food, only drinking Glucerna.

On the allegation: Staff neglected Resident #1 (R1) resulting in R1 developing stage 4 pressure injuries. The administrator and staff described how R1’s pressure injuries progressively worsened, R1 refused to eat, R1 complained of pain and R1’s condition worsened. Additionally, repositioning logs only show R1 was repositioned between 5/1/2022 and 5/24/2022, but there are no repositioning logs to show R1 was repositioned after 5/24/2022, and R1’s condition worsened. The administrator stated medical attention was pursued on 05/27/2022 only after R1’s resident representative requested it, and it was determined R1 had a septic Stage 4 pressure injury.
Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 29-AS-20220620111537
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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Based on record review and interviews the facility documented pressure injuries progressively worsening with the possibility of infection, yet no action was taken by the facility to seek medical attention, therefore the allegation is deemed Substantiated at this time.

On the allegation: Facility staff failed to seek medical attention in a timely manner for Resident #1 (R1) contributing to R1’s stage 4 pressure injuries. The administrator had been instructed by the home health nurse on numerous visits to seek urgent medical attention if R1’s symptoms worsened. The administrator sought medical attention on 05/27/2022 only after R1’s resident representative requested it. Based on record review and interviews, the facility failed to seek medical attention in a timely manner when R1 started declining, when R1 refused to eat, and when R1’s pressure injuries progressively worsened, therefore the allegation is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Administrator/Licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)

Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (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 7
Control Number 29-AS-20220620111537
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
87468.2(a)(4)
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87468.2(a)(4) Personal Rights...residents ... shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Licensee will submit a plan how they will ensure all residents receive proper care and supervision to CCL by 11/17/22
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This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when R1 was not given the proper care/supervision for worsening pressure injuries, which posed an immediate health and safety risk to residents in care.
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An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)
Type A
11/17/2022
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section
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Licensee will submit plan how you will ensure residents receive timely medical care. Submit to CCL by 11/17/22
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cited above when the licensee did not seek medical attention in a timely manner when R1 started declining, refused to eat, and when R1's pressure injuries progressively worsened, which posed an immediate 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: 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)
Page: 3 of 7