565802464-3-27-2024-29-AS-DPEA-D3U44W-20240329184700

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802464
Report Date: 03/27/2024
Date Signed: 03/27/2024 12:12:05 PM

Substantiated

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
05/23/2023 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20230523101459

FACILITY NAME:	EMBRACING SENIORS		FACILITY NUMBER:	565802464
ADMINISTRATOR:	TRUPIANO, JOSEPH		FACILITY TYPE:	740
ADDRESS:	729 MUIRFIELD AVE		TELEPHONE:	(805) 422-8441
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 4	DATE:	03/27/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Regie Dulay, Staff		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident sustained pressure injuries while in care.
Resident sustained unexplained bruises due to staff negligence.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA met with staff Regie Dulay and explained the reason for the visit. Staff contacted Licensee/Administrator Joseph Trupiano who stated that he is unable to come to the facility due to transportation issues. LPA reviewed the investigation findings with Mr. Trupiano over the phone. Mr.Trupiano stated that staf may sign the report.
On 05/23/2023, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that Resident #1 (R1) sustained unstageable pressure injuries while in facility care and R1 sustained unexplained bruising due to staff negligence. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Heidy Bendana. This case was also referred to the Department’s Program Clinical Consultant (PCC) for review. On 05/24/2023, LPA Chochian conducted an initial 10-day complaint visit for the above allegations.During the visit, the LPA toured the facility with staff at approximately 10:00 a.m., reviewed resident records between 10:15 a.m. to 10:30 a.m., and obtained copies of pertinent records. (Continue to LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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 29-AS-20230523101459

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: EMBRACING SENIORS	FACILITY NUMBER: 565802464
	VISIT DATE: 03/27/2024

NARRATIVE

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Investigator Bendana conducted interviews on 07/11/2023, at approximately 1:47 p.m., with Staff #1 (S1), Staff #2 (S2), Resident #2 (R2), and attempted to interview Resident #1 (R1) but R1 did not respond to questions or acknowledge the investigator; on 08/16/2023, from approximately 10:58 a.m. to 11:14 a.m., with the hospice nurse and R1’s resident representative; on 08/21/2023, at approximately 3:01 p.m., with the administrator; on 08/22/2023, at approximately 11:36 a.m., with the wound care specialist certified nurse; on 09/01/2023, at approximately 1:14 p.m., re-interviewed the administrator; and on 09/05/2023, at approximately 3:49 p.m., attempted to re-interview S1. In addition, the investigator reviewed R1’s medical records, photos of R1’s pressure injuries and bruises, and facility file documents related to R1.

R1’s Physician Report, dated 02/27/2023, listed R1’s primary diagnosis as Alzheimer/Dementia. R1 needed assistance with all activities of daily living, needed routine check for skin breakdown, was considered non-ambulatory, and needed assistance transferring to and from bed. R1’s Appraisal Needs and Services Plan, dated 02/15/2023, documented R1 needed assistance with all activities of daily living, needed assistance when ambulating, and was a fall risk.

A review of the text messages sent between the administrator and R1’s resident representative revealed that on 05/12/2023, at 12:42 p.m., the administrator notified R1’s resident representative that R1 had a rash on the left shoulder and hip and needed to be seen by a doctor. R1’s resident representative took R1 to the primary care physician on 05/15/2023 where R1 was assessed. During the visit, the nurse practitioner addressed a pressure injury of R1’s buttocks at stage 2, unspecified laterality. R1 was prescribed Doxycycline Hyclate and Mupirocin ointment. The orders included pressure setting on bed at the facility and move positions every two (2) hours to prevent damage to the skin. R1 was referred to the Tarzana Wound Care Center for further evaluation. On 05/22/2023, at 2:00 p.m., the wound care center noted multiple pressure injuries including right and left hip unstageable pressure injuries; left scapula deep tissue pressure injury; and right and left buttock stage 2 pressure injuries. R1 was also noted to have bruising on the right forehead and bilateral knees, the right knee worse than the left. R1 was referred to the Adventist Health Simi Valley Emergency Room for further evaluation.

A review of the Adventist Health Simi Valley medical records revealed that on 05/22/2023, R1 was seen in the Emergency Room with the chief complaint of open wound in the coccyx, left buttock, and left shoulder since 05/12/2023. R1 was admitted to the hospital for further management and a wound care specialist consultation. (Continue to LIC9099C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20230523101459

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: EMBRACING SENIORS	FACILITY NUMBER: 565802464
	VISIT DATE: 03/27/2024

NARRATIVE

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It was noted that R1 had several areas of bruising to the lower extremities that suggests R1 had fallen relatively recently. The evaluation noted “evidence of ecchymosis (bruising) of the right knee consistent with a recent fall, there is also a deep wound to the right hip that may be related to the same injury”. Imaging was conducted and there was no evidence of fractures. The assessment included R1 had pressure ulcers, noting R1’s right hip wound appeared to be relatively deep and may be partially gangrenous. R1 was diagnosed with unspecified open wound of lower back and pelvis, stage 1 pressure ulcer of sacral region, unstageable pressure ulcer of left and right hip, and pressure induced deep tissue damage of right and left upper back. On 05/24/2023, R1 was discharged to hospice care.

On the allegation “Neglect/Lack of Supervision - Resident sustained pressure injuries while in care”. The Department’s investigation provided sufficient evidence to substantiate the allegation. The interviews and medical records noted R1 had unstageable pressure injuries. The staff reported they repositioned R1 twice a day, in the morning and in the evening. Due to R1’s condition, R1 needed to be repositioned more than twice a day. The administrator and the staff were aware the pressure injuries were “progressively” worsening. The staff failed to reposition R1 every two (2) hours as instructed in the discharge notes. The staff failed to provide care according to the after-visit care plan. The facility neglected R1 causing pressure injuries to develop and progressively worsen. Therefore, the allegation “Neglect/Lack of Supervision - Resident sustained pressure injuries while in care” is deemed substantiated at this time.

On the allegation “Neglect/Lack of Supervision - Resident sustained unexplained bruises due to staff negligence”. The Department’s investigation provided sufficient evidence to substantiate the allegation. During R1’s evaluation at the hospital, it was noted that R1 had several areas of bruising to the lower extremities that suggests R1 had fallen relatively recently. Based on R1’s facility file documents, R1 was a known fall risk. When initially questioned if R1 had any falls at the facility, the administrator and staff denied any falls. The administrator was later informed by S1 that R1 had slipped in the bathroom. Therefore, the allegation “Neglect/Lack of Supervision - Resident sustained unexplained bruises due to staff negligence” is deemed substantiated at this time.

A $500 immediate civil penalty is assessed today. The Licensee/Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).
Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D)
Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230523101459

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: EMBRACING SENIORS	FACILITY NUMBER: 565802464
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/28/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to submit a plan on how they will ensure that residents are provided 24-hour care and supervision to meet their individual health care needs. Submit to CCL by POC due date.
	8 9 10 11 12 13 14	Based on medical records, photos, and interviews, licensee did not comply with the section cited. Staff did not provide the necessary care and supervision resulting in R1 sustaining pressure injuries and bruising while in care, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)
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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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC9099 (FAS) - (06/04)

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