435294300-11-6-2020-26-AS-JJIN-BV4RAV-20201106115146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294300
Report Date: 11/06/2020
Date Signed: 11/06/2020 11:52:13 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	APRIL GARDEN VILLA OF SARATOGA		FACILITY NUMBER:	435294300
ADMINISTRATOR:	TAN, THELMA		FACILITY TYPE:	740
ADDRESS:	12226 PLUMAS DRIVE		TELEPHONE:	(408) 777-8043
CITY:	SARATOGA	STATE: CA	ZIP CODE:	95070
CAPACITY:	5	CENSUS: 5	DATE:	11/06/2020
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Valentin De La Fuente, Licensee and Thelma Tan, Administrator		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/06/2020 Licensing Program Analyst, Jackie Jin, met with Valentin De La Fuente, Licensee and Thelma Tan, Administrator for a case management visit to follow up with a substantiated complaint regarding neglect/lack of care and supervision. On July 21, 2016, the Department concluded a complaint investigation which alleged the following: facility staff failed to obtain timely medical care for a resident (R1) which resulted in R1 developing a stage 4 pressure injury, facility failed to request exception for R1, and facility staff failed to meet the needs of R1. The allegations were substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87465(a)(1) Incidental Medical and Dental Care Services for failure to arrange or assist in arranging medical care for R1 resulting in R1 developing a stage 4 pressure injury. Licensee was also cited for CCR Title 22 §87615(a)(1) Prohibited Health Conditions for retaining a resident with a prohibited health condition without an exception. In addition, licensee was cited for CCR Title 22 §87411(a) Personnel Requirements for failure to have competent personnel staff members to meet R1’s needs. Staff failed to provide adequate care after observing the change in R1’s condition. The investigation revealed that on December 30, 2015 R1 was admitted to the facility with a bump on R1’s coccyx that was a size of a dime. R1’s skin was intact, slightly red color and did not look like a pressure injury. In February 2016 (exact date not recalled per interview), a caregiver at the facility noticed the bump turned a dark color and the size increased to a quarter and notified the administrator (S1). S1 treated the area with Duoderm and antibiotic spray after showers and diaper changes. S1 instructed the caregivers to do the same while S1 was not at the facility. S1 did not notify R1’s doctor or family member about the wound.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: APRIL GARDEN VILLA OF SARATOGA	FACILITY NUMBER: 435294300
	VISIT DATE: 11/06/2020

NARRATIVE

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On March 17, 2016, R1’s son was at the facility, but S1 failed to notify R1’s son about the wound. On March 18, 2016, R1 refused to eat and R1’s son was notified. S1 and R1’s son both agreed to send R1 to the hospital.

On March 18, 2016 R1 was admitted to a general acute care hospital for shortness of breath, altered level of consciousness, and not eating. R1 was diagnosed with metabolic encephalopathy (per medical-dictionary.com is an alteration of brain function or consciousness due to failure of other internal organs, electrolyte imbalances or inadequate brain perfusion) due to sepsis (which per Mayo Clinic, the body releases chemicals in to the bloodstream to fight an infection. Sepsis occurs when the body’s response to these chemicals is out of balance, triggering changes that can damage multiple organ systems), pneumonia, Bacteremia with beta-hemolytic Strep constellatus (per medical-dictionary.com is a strain of bacteria), acute on chronic kidney disease due to dehydration, dementia, hypothyroidism, hypertension and hyponatremia hypovolemic. Wound care consultant at the hospital noted that R1 had a stage 4 pressure injury in the coccyx area measured at 2 x 2.1 x 0.8 cm. Per hospital records, wound was heavily colonized and not likely to heal without surgical intervention which would not be indicated given patient’s age and code status.

R1 was discharged from the hospital on March 22, 2016 to a skilled nursing facility for wound care. R1 was readmitted to the general acute care hospital on March 28, 2016 for Sepsis secondary to pneumonia and stage 4 sacral pressure injury. R1’s pressure injury will not improve without surgery. R1 was discharged back to the skilled nursing facility on April 1, 2016 with hospice services.

Based on interviews, observations, and record review, the licensee failed to seek timely medical attention and intervention when the resident’s skin condition worsened which involved physical pain. Furthermore, the licensee failed to provide a pressure relieving device timely to prevent the development of a stage 4 pressure injury, thus prolonging pain and suffering. The licensee also retained R1 with a prohibited health condition (stage 4 pressure injury) prior to obtaining an approval from the Department.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: APRIL GARDEN VILLA OF SARATOGA	FACILITY NUMBER: 435294300
	VISIT DATE: 11/06/2020

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The Department has concluded the analysis and has determined that a civil penalty is warranted for serious bodily injury. Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a bodily member, organ, or of mental facility, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, 11/06/2020, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 in the amount of $10,000 for a violation that the Department constitutes as a serious bodily injury. A copy of the LIC 421D was given to Valentin De La Fuente, Licensee and Thelma Tan, Administrator and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Valentin De La Fuente, Licensee and Thelma Tan, Administrator signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020

LIC809 (FAS) - (06/04)

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