445202740-10-31-2023-26-AS-KHOS-D8RGYZ-20240903054622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202740
Report Date: 10/31/2023
Date Signed: 10/31/2023 04:45:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
08/03/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20230803151208

FACILITY NAME:	COBBLESTONE MANOR		FACILITY NUMBER:	445202740
ADMINISTRATOR:	JIMENEZ, ISABEL		FACILITY TYPE:	735
ADDRESS:	75 LINDEN ROAD		TELEPHONE:	(831) 818-7981
CITY:	WATSONVILLE	STATE: CA	ZIP CODE:	95076
CAPACITY:	4	CENSUS: 4	DATE:	10/31/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Miguel Vega		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff did not provide adequate medical attention for resident in care.

INVESTIGATION FINDINGS:

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LPA Marrufo arrived at the facility to conduct an unannounced complaint investigation visit and met with Miguel Vega.

On 08/03/2023, the Department received a complaint with the above allegation. On 08/10/2023, LPA Marrufo conducted an initial complaint investigation visit.

R1’s Physician Visit form dated 06/12/2023 states that R1 was referred to the Emergency Room (ER) from the Radiology Outpatient Department for a right knee fracture. R1’s attending physician states in the form that R1 has a femur fracture above the right knee and the fracture appears to be an old fracture that already showed signs of healing. The form states a knee immobilizer was placed until follow up with the orthodontist.

See LIC9099-C for more information. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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 4

Control Number 26-AS-20230803151208

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: COBBLESTONE MANOR	FACILITY NUMBER: 445202740
	VISIT DATE: 10/31/2023

NARRATIVE

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R1’s Record of Consumer Medical Care states that on 06/20/2023, R1 visited R1’s orthopedic physician to inform the orthopedic physician of pressure injuries that resulted from R1’s knee immobilizer. The entry from 06/21/2023 states Administrator of the facility inquired with R1’s orthopedic physician if the knee brace can be removed during bedtime, but the orthopedic physician advised Administrator that R1 needs to keep the knee brace throughout the day, otherwise R1’s healing time may be prolonged. R1’s orthopedic physician recommended treatment of applying additional material on either ends of R1’s knee immobilizer to prevent metal rods from exiting and piercing R1’s skin and to elevate R1’s leg with pillows.

During interview on 08/10/2023, Administrator Isabel Jimenez stated that resident R1 had experienced a fracture and was prescribed a knee stabilizer. Administrator Jimenez stated R1’s knee stabilizer had metal rods that poked and cut R1’s skin causing R1 to become wounded. Administrator Jimenez stated R1 was taken to the hospital for the wounds and was discharged back to the facility and received an approved restricted health care plan.

On 10/31/2023, LPA Marrufo conducted interviews with staff S1-S3. 3 out of 3 interviewed staff stated that facility staff put cloths between the rods of R1’s knee stabilizer to prevent the rods from wounding R1. 3 out of 3 interviewed staff state that staff put two pillows underneath R1’s leg and use an additional neck pillow around R1’s leg to provide additional comfort.

Based on information from interviews conducted with staff, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Miguel Vega and a copy of this report was provided.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4