565850217-9-18-2024-29-AS-KHEN-D9HPUK-20240927113740

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850217
Report Date: 09/18/2024
Date Signed: 09/18/2024 11:57:23 AM

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
08/13/2024 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20240813154536

FACILITY NAME:	WE CARE SENIOR FACILITY LLC		FACILITY NUMBER:	565850217
ADMINISTRATOR:	HORDAGODA, SHASHIKA		FACILITY TYPE:	740
ADDRESS:	3350 EL NIDO ST		TELEPHONE:	(818) 571-1905
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 1	DATE:	09/18/2024
		UNANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Shashika Hordagoda		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not ensure there was enough food for residents in care
Staff are not following physician’s orders

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility unannounced at 10:37AM and initially met with facility staff. Licensee was contacted via telephone and arrived at the facility shortly after the visit began. Entrance interview conducted.

During an initial visit conducted on 08/13/2024, LPAs Kelly Dulek and Teresa Camara interviewed staff at 04:46PM, resident at 04:55PM, and Administrator/Licensee at 05:13PM. LPAs also observed the facility food supply, took a brief facility tour, and reviewed and obtained copies of available pertinent documents. Throughout the course of the investigation, LPA Dulek reviewed all pertinent documents, including text message conversations and interviewed other relevant parties. The following was then determined:

Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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-20240813154536

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: WE CARE SENIOR FACILITY LLC	FACILITY NUMBER: 565850217
	VISIT DATE: 09/18/2024

NARRATIVE

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Allegation: “Staff did not ensure there was enough food for residents in care:”

During a visit at the facility on 08/08/2024, LPAs Dulek and Camara conducted a facility tour and observed the facility food. The facility was issued a citation for insufficient amounts of food and as a plan of correction, the facility agreed to purchase additional perishable food supply in all food groups. On 08/12/2024, the licensee sent photographs of additional purchased food present in the facility. Although the complaint was received on 08/13/2024, it was observed that Resident #1 (R1), who is mentioned in the complaint, was hospitalized as of 08/09/2024. At the time that R1 left the facility, there was still an insufficient amount of food. Record review revealed that R1 is diabetic and therefore has a diabetic diet indicated on one physician’s report and another indicates “no concentrated sweets.” During the visit conducted on 08/08/2024, LPAs observed R1’s breakfast to be pancakes with syrup. Staff attempted to give R1 regular syrup, however R1 refused and had to repeat multiple times to the staff that R1 requires sugar free syrup. Based on observation, the allegation “staff did not ensure there was enough food for residents in care” is deemed SUBSTANTIATED at this time. As the facility was cited for this violation on 08/08/2024, no additional citation will be issued related to this allegation at this time.

Allegation: “Staff are not following doctor’s orders:”

The complaint alleges that staff are not following doctor’s orders related to R1’s blood sugar readings, medications and reporting to R1’s physician. LPA interviewed staff and Licensee, who indicated R1 was initially on both a regular dose of insulin as well as sliding scale insulin, however, R1’s doctor had discontinued the sliding scale some time ago. Record review revealed that R1’s medications and physician orders had changed multiple times while R1 resided at the facility. LPA did observe doctor’s orders dated 12/05/2022 indicating call doctor if blood sugar level is over a certain reading. This medication (Novalog) was discontinued by R1’s doctor on 10/03/2023. Then on 10/27/2023, R1’s primary care physician ordered sliding scale for the Novalog and then changed the parameters on 11/03/2023, but the medication was still ordered to be administered. However, R1's family member told Licensee to only follow orders given by R1's kidney doctor related to R1's diabetic needs, so this medication was not administered after 10/03/2023. Additionally, hospital discharge paperwork dated 07/06/2024 indicate 3 new medications: insulin Glargine to be administered a regular dose twice daily, insulin Lispro to be administered a regular dose three times daily, and insulin Lispro on a sliding scale 4 times daily. Hospital discharge records also ordered R1’s Tresiba and Januvia to be discontinued. Again, R1's family member told staff not to follow hospital orders, but no Report Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240813154536

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: WE CARE SENIOR FACILITY LLC	FACILITY NUMBER: 565850217
	VISIT DATE: 09/18/2024

NARRATIVE

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clarification in writing was provided by R1's kidney doctor, nor any other licensed medical professional. LPA reviewed R1’s medication list as well as Medication Administration Record (MAR), which revealed that none of these new medications were obtained nor administered to R1. Additionally, MAR for January 2024 – August 2024 did not indicate Tresiba was administered, even though R1's kidney doctor had ordered this medication and it was scheduled to be administered daily. Based on interview and record review, the preponderance of evidence standard has been met, therefore, the allegation “staff are not following doctor’s orders” is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20240813154536

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: WE CARE SENIOR FACILITY LLC	FACILITY NUMBER: 565850217
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/18/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	R1 no longer resides at the facility. Licensee understands to communicate with the residents' doctors directly and only follow written instructions ordered by the physician. POC cleared.
	8 9 10 11 12 13 14	Based on interview and record review, R1's doctor's orders were not followed as multiple doctors were ordering medications and the licensee followed R1's family member's verbal instructions on which to follow and medications were not documented, which posed a potential health risk to residents.	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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

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