445202247-6-4-2021-26-AS-KHOS-C3ZKTP-20210615081129

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202247
Report Date: 06/04/2021
Date Signed: 06/04/2021 03:43:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2020 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20201002120659

FACILITY NAME:	TWIN LAKES MANOR		FACILITY NUMBER:	445202247
ADMINISTRATOR:	JENNIFER FLORES		FACILITY TYPE:	740
ADDRESS:	777 VOLZ LANE		TELEPHONE:	(831) 477-1100
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	12	CENSUS:	DATE:	06/04/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Jennifer Flores		TIME COMPLETED:	03:42 PM

ALLEGATION(S):

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Staff did not obtain medical treamtement for resident in a timely manner.
Staff did not assess resident after the fall.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryker Heberle And Roadilla conducted an unannounced visit to close an investigation on the above allegations. LPAs met with Administrator Jennifer Flores (Admin).

During a complaint investigation visit on 10/15/2020. LPA interviewed a staff member (S1) who detailed the events of resident's (R1) fall. R1 was taken for a walk at approximately 1:00pm. At the end of the walk, R1 fell on his/her right side. S1 asked R1 what his/her pain levels were, and R1 stated that it was an 8 out of 10. R1 was administered excedrin, at which point he/she indicated that the pain was at about a 5/10. R1 later indicated to S1 that the pain had begun to get worse again at 02:30pm. According to interview with Admin on 10/15/2020, there was no indication of a broken leg immediately after R1's fall.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

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 5

Control Number 26-AS-20201002120659

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: TWIN LAKES MANOR	FACILITY NUMBER: 445202247
	VISIT DATE: 06/04/2021

NARRATIVE

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In interview with S1 on 06/01/2021, LPA asked S1 what the facility did to assess R1 after the fall. S1 stated that they asked R1 his/her pain level, assisted R1 into a wheelchair, then gently patted R1's leg asking where it hurt. Pain assessment occurred after staff had moved R1 into wheelchair. Fall Detail Report from the day of the incident does not indicate the extent of fall assessment. Staff training logs do not have staff or administrator signatures designating completion of fall response training for staff members present during the time of the fall.

In an interview with resident's Primary Care Physician on 05/12/2021, PCP stated that he/she was never directly contacted by the facility. PCP first became aware of R1's fall in a phone call with R1's spouse that occurred at 8:59pm, 8 hours after the fall.

PCP indicated that R1 had previously had bad experiences with the hospital, and had stated that he/she never wanted to go to the hospital ever again. Despite this, PCP expressed concern over the fact that the facility did not call him/her or paramedics directly after the fall, as the injury sustained warranted immediate medical treatment. PCP does not believe that R1 would have agreed to go to the hospital, but that R1's pain and discomfort could have been more directly addressed.

In an interview with Admin on 10/15/2020, Admin indicated to LPA that R1 expressed desire to go to the hospital, but R1's spouse did not want R1 to go as it was too late at night. R1 did not go to the hospital and paramedics were not called.

R1's death certificate indicated R1's cause of death to be complications from a broken hip.

The Department has conducted an investigation of the above allegations. Based on LPAs’ interviews, and record review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED.

Deficiencies cited per the California Code of Regulations Title 22, see attached 9099-D. Civil penalty in the amount of $500 was assessed today. Additional civil penalty for the violation resulting in death is pending further review. Report reviewed with Jennifer Flores, Administrator during exit interview and a copy of this report provided with appeal rights.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20201002120659

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: TWIN LAKES MANOR	FACILITY NUMBER: 445202247
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/05/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) - Personnel Requirements- 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	Facility will conduct staff trainings on providing proper assessment of resident injury and fall prevention. POC due date is 06/05/2021 and proof of completion of training to be provided upon completion.
	8 9 10 11 12 13 14	Based on interviews, staff did not follow the facility protocol in assessing R1 prior to moving and putting R1 back in his/her wheelchair. R1 sustained broken hip and passed away from complications of broken hip. An immediate civil penalty in the amount of $500 was assessed. Civil penalty in the amount of $15,000 for violation resulting in death is pending review.	8 9 10 11 12 13 14
Type A 06/05/2021 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465(g) Incidental Medical and Dental Care - The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility will conduct staff trainings on when it is appropriate to alert ermergency services or medical personnel in regards to resident incidents. POC due date is 6/05/2021 and proof of completion of training to be provided upon completion.
	8 9 10 11 12 13 14	Based on interviews, 911 was not called after fall in which resident's hip was broken, despite indication of intense pain. This posed an immediate risk to the health & safety of R1.	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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2020 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20201002120659

FACILITY NAME:	TWIN LAKES MANOR		FACILITY NUMBER:	445202247
ADMINISTRATOR:	JENNIFER FLORES		FACILITY TYPE:	740
ADDRESS:	777 VOLZ LANE		TELEPHONE:	(831) 477-1100
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	12	CENSUS:	DATE:	06/04/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Jennifer Flores		TIME COMPLETED:	03:42 PM

ALLEGATION(S):

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Staff did not notify responsible party of injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryker Heberle and Joanne Roadilla conducted an unannounced visit to close an investigation on the above allegations. LPAs met with Administrator Jennifer Flores (Admin).

According to interview with Admin on 10/08/2020, after resident's (R1) fall, facility attempted to inform his/her spouse (RP), but was unable to reach him/her. In interview with RP on 10/08/2020. RP stated that there was a period of time after R1's fall in which RP's phone was accidentally left off the hook, during which facility could have been trying to call. RP stated that facility staff called to inform him/her of the incident approximately 8 hours after the fall.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20201002120659

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: TWIN LAKES MANOR	FACILITY NUMBER: 445202247
	VISIT DATE: 06/04/2021

NARRATIVE

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The Department has investigated the above allegation. Based on interviews conducted and records reviewed, the Department found that the above allegation to be UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

Report reviewed with Jennifer Flores, Administrator, and a copy of this report provided for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5