565801979-5-23-2023-29-AS-JAPL-CS8TTR-20230527150111

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801979
Report Date: 05/23/2023
Date Signed: 05/23/2023 01:45:51 PM

Unsubstantiated

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
10/25/2021 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20211025120711

FACILITY NAME:	WELLNESS CARE SENIOR LIVING		FACILITY NUMBER:	565801979
ADMINISTRATOR:	ALEIDA ALONSO		FACILITY TYPE:	740
ADDRESS:	158 ROCKAWAY ROAD		TELEPHONE:	(805) 649-5143
CITY:	OAK VIEW	STATE: CA	ZIP CODE:	93022
CAPACITY:	56	CENSUS: 25	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maria Hernandez		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff failed to notify authorized representative regarding resident fall

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with Administrator Maria Hernandez and explained the reason for the visit. On 10/25/2021, the Department received a complaint, alleging that staff failed to report Resident #1’s (R1) fall to R1’s responsible party. LPA Joann Rosales conducted an initial visit on 11/04/2021, to which LPA Rosales interviewed staff, reviewed resident records, and obtained documents between 11:15 a.m. – 3:20 p.m. Today, LPA Ashley Smith interviewed four (4) staff and four (4) residents from 9:00 a.m. – 1:00 p.m.

It is the claim that during the first week of January 2020, when R1’s family visited R1 at this facility, R1 complained of pain and presented with an unsteady walk. With the aims of ruling out a stroke, R1 was seen in the emergency room. Per the emergency room visit, there was no evidence of a stroke, yet R1 was instructed to follow up with their primary care doctor. Allegedly at the follow-up appointment, a staff member also attended the appointment and reported to the doctor that R1 had previously fallen.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211025120711

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: WELLNESS CARE SENIOR LIVING	FACILITY NUMBER: 565801979
	VISIT DATE: 05/23/2023

NARRATIVE

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It’s alleged that R1’s responsible party was unaware of this fall until R1’s follow-up doctor’s appointment.

Interviews and record review revealed that on 1/4/2020, staff reported to facility management that R1’s hand was swollen. A review of care notes obtained on 11/04/2021 documented that R1’s right wrist appeared to be swollen, was walking unsteady, and R1 also complained of back pain. R1 was assisted with the self-administration of pain medication, which appeared to have worked. R1’s family arrived at the facility later that day. Once hearing about the pain, R1's family indicated that R1 had suffered with arthritis, and R1’s family member allegedly ‘was not concerned’ with R1’s pain. However, R1’s family made the decision to take R1 to the emergency room on 01/04/2020. R1 returned to the facility hours later with no new orders, yet was advised to obtain a magnetic resonance imaging (MRI) scan to rule out the possibility of a stroke.

A review of facility nursing progress notes indicated that R1 had a follow up appointment on 1/9/2020 and 1/23/2020 to conduct labs and for additional referrals. However, there was no indication that staff attended either of these appointments. Records reviewed indicated that R1 had a follow-up doctor’s appointment on 1/30/2020, in which notes indicated that R1 had been experiencing pain in the right hip for the past month. It was documented that R1 had suffered a fall on 01/06/2020, yet there was no further documentation as to whom communicated this information to the doctor. X-ray imaging completed on R1’s hip displaced no degenerative changes, no abnormalities, or arthritis. Yet, a review of resident records and interviews were unable to provide corroborating evidence that R1 had suffered a fall, or that staff had reported a fall.

Staff interviews revealed inconclusive information regarding this incident. An interview was conducted with the staff who was identified as attending the follow up doctor’s appointment; however, this staff denied claims that they were present during this visit and denied claims that they communicated to R1’s responsible party that R1 had suffered a fall. Staff who had provided care to R1 confirmed recollection of R1 having a swollen hand. However, staff denied knowledge of R1 suffering a fall. Staff interviews indicated that if a resident suffers a fall or is presumed to have fallen, staff would have reported to the clinic staff, and it would have been documented on an incident report. In addition, it would have been reported to a responsible party.

Based on the information obtained from interviews and record review, there is insufficient evidence to support the claim staff failed to report R1’s fall to R1’s responsible party. Although the allegation may have happened or is valid, there is insufficient evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

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