455002676-12-7-2023-25-AS-LCRR-CZ7TKC-20240105134742

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 455002676
Report Date: 12/07/2023
Date Signed: 12/07/2023 11:11:46 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/17/2023 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 25-AS-20230217110723

FACILITY NAME:	WESTSIDE ASSISTED LIVING		FACILITY NUMBER:	455002676
ADMINISTRATOR:	ENEIX, AUDRA		FACILITY TYPE:	740
ADDRESS:	915 HALLMARK DR		TELEPHONE:	(530) 605-4041
CITY:	REDDING	STATE: CA	ZIP CODE:	96001
CAPACITY:	6	CENSUS: 6	DATE:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Audra Eneix		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Resident sustained pressure injuries while in care

INVESTIGATION FINDINGS:

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LPA Hiratsuka conducted this visit to deliver the results of the investigation above. LPA met with Audra Eneix.

During the course of the investigation the staff, home health care agency staff, and several witnesses were interviewed. Medical records were reviewed. Partial facility records were reviewed.

Based on records, R1 moved in the end of October 2022. Between the date R1 moved in to February 2023, R1 developed multiple pressure injuries. Per medical records Braden Risk Assessments (BRA) were conducted on 11/03/2023 and was a low risk for developing pressure injuries. A BRA was conducted on 12/03/2023 and the risk to R1 was moderate. R1 was diagnosed with a stage II pressure injury on 12/20/2022. On 12/22/2022, R1 another BRA was conducted, and R1 was deemed a low risk. On 12/22/2022, R1 was diagnosed with an unstageable pressure wound. 12/27/2022, a stage II pressure injury was diagnosed. 12/31/2023, a stage I pressure injury was diagnosed. 01/06/2023, another stage one pressure injury was diagnosed.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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 3

Control Number 25-AS-20230217110723

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WESTSIDE ASSISTED LIVING	FACILITY NUMBER: 455002676
	VISIT DATE: 12/07/2023

NARRATIVE

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On 02/03/2023, two new stage II pressure injuries were diagnosed. On 02/10/2023, a possible abscess formation was found, and the resident was sent to the hospital. Hospital records show one of the pressure injuries was a stage IV.

Records from the home health care agency indicate staff were trained on proper positioning of R1 and perform pressure relief and instructed to reposition R1 ever hour if possible. Staff were educated to perform frequent positional changes at night. Home Health Agency was treating R1 twice a week. A home health care nurse stated R1 was incontinent, and the nurse would find R1 frequently saturated and times where it was obvious R1 was not changed during the night.

Interviews and medical records indicate R1 suffered a traumatic event and voiced that they were feeling sadness, no appetite, and felt less willing to move around. A note was found next to R1’s bed that stated R1 was to be in bed except during meals and the nurse stated they did not agree with the note and stated R1 was still able to sit up and staff were instructed to get R1 out of bed. There was a referral for mental health treatment but there are no notes indicating how long the resident was under mental health care or what staff were to do for the resident’s mental health. Interviews with staff did not mention ways staff were to monitor the resident for any changes. Home health nurse suggested R1 go to a wound care clinic once a week because the pressure injuries were not healing, and it was denied by the facility with no explanation.

Based on the above, the needs of R1 were not met by the facility.

As a result of this investigation, the Department finds the allegations above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations and California Health and Safety Code. At the time of the complaint visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations Section 87463(a). The Administrator was informed that a civil penalty was under review and may be assessed at a future date according to Health and Safety Code 1569.49.

Exit interview conducted. A copy of the report has been issued. Appeal Rights provided. signature on this report acknowledges receipt of the Appeal Rights

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20230217110723

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WESTSIDE ASSISTED LIVING	FACILITY NUMBER: 455002676
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/08/2023 Section Cited HSC 1569.312(e)	1 2 3 4 5 6 7	Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.	1 2 3 4 5 6 7	By 12/08/2023, the licensee shall submit in writing a written plan of correction on how they shall ensure residents are monitored. $500.00 immediate civil penalties issued for today's citation.
	8 9 10 11 12 13 14	This requirement was not met as evidenced based by; upon records reviewed and interviews, R1 developed multiple pressure injuries while in care due to needs not being met by facility staff. This poses 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: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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