565850351-6-20-2024-29-AS-KLOZ-D6NVKB-20240628163003

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850351
Report Date: 06/20/2024
Date Signed: 06/20/2024 01:13:24 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
01/05/2024 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20240105155510

FACILITY NAME:	JM'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	565850351
ADMINISTRATOR:	OHIDE, JOSEPH		FACILITY TYPE:	740
ADDRESS:	2221 KEPLER DR		TELEPHONE:	(805) 202-9208
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 1	DATE:	06/20/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Crisostomo Libutan-Caregiver		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff failed to provide adequate care and supervision for a resident who uses a catheter
Staff are not providing appropriate care and supervision to the resident while in care of feeding tube
Staff do not ensure resident's personal hygiene needs are met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Cortez met with staff Cristosostomo Libutan and explained the reason for the visit. Administrator Rodolfo Ohide was contacted via phone and the reason for the visit was explained. Administrator was unable to be at the facility during today’s visit and authorized Crisostomo Libutan to sign and receive the report.

On 01/05/2024, the Department received a complaint regarding allegations of lack of care. Resident #1 (R1) utilizes a catheter and sustained injury. R1’s urethra split, resulting in infection and scrotum swelling. In addition, R1 utilizes a feeding tube and was observed with crust around the site of their PEG (Percutaneous Endoscopic Gastronomy) tube. The complaint also alleged that R1’s hygiene was poor as R1 was observed with dirty feet. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Edward Hector. Report will continue on LIC9099-C (2ND PAGE).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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-20240105155510

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JM'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 565850351
	VISIT DATE: 06/20/2024

NARRATIVE

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On 01/08/2024, from 10:20am to 3:00pm, Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced complaint visit to investigate the allegations listed above. Upon arrival LPA Cortez met with staff Beth Mangune and explained the reason for the visit. The administrator Rodolfo Ohide was contacted via phone and the reason for the visit was explained. The administrator was unable to be at the facility during the visit, however administrator authorized staff Beth Mangune to review and sign the report. Between 10:50am and 2:30pm the LPA toured the physical plant, interviewed the administrator, conducted a file review, and obtained copies of pertinent documents relevant to the investigation. The LPA determined further investigation was required and advised the administrator and staff that the complaint was referred to the Community Care Licensing Division (CCLD) Investigation Branch (IB) and assigned to Investigator Edward Hector.

Investigator Hector conducted interviews on 02/21/2024, at 3:40pm, with R1 (attempted), and at 3:46pm, with Staff #1 (S1); on 02/26/2024, at 12:51pm, with Los Robles Health Care at Home (LRHH) home health nurse supervisor; and on 03/08/2024 from 12:19pm to 6:35pm, with the LRHH nurse supervisor, Tri-Counties Regional Center (TCRC), and R1’s resident representative. In addition, the investigator reviewed medical records from Community Memorial Hospital (CMH), LRHH home health agency, and facility file documents related to R1.

According to R1’s resident appraisal, R1 required total physical care for all activities of daily living (ADLs). R1 was diagnosed with autism, cognitive impairment, and used limited expressive communication. R1 also suffered from an enlarged prostate and was on a pureed diet. Additional facility file documents indicated R1 was non-ambulatory and bedridden, with health status listed as poor. R1 had a history of urinary tract infections (UTIs), sepsis, required the use of a catheter, and due to a failure to thrive a PEG (Percutaneous Endoscopic Gastronomy) tube was placed on 10/03/2023. The records reviewed indicated R1 was being seen by LRHH home health agency three (3) times per week for palliative care, which included monitoring and care for catheter, PEG tube, and wound care.

According to the medical records, R1 was admitted to CMH on 01/03/2024 due to having a fever, that began the day prior. (R1 had been recently seen at the emergency department for a UTI and was already receiving antibiotics for the UTI). R1 was admitted with sepsis, felt to be secondary to recurrent urinary tract infection. R1 was also documented as being observed with scrotal swelling that was possibly "related to overall fluid overload." Report will continue on LIC9099-C (3RD PAGE).

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20240105155510

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JM'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 565850351
	VISIT DATE: 06/20/2024

NARRATIVE

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R1’s foley catheter was exchanged. When the catheter was replaced, urine returned but urethral erosion was noted. The medical records list, "Foley catheter appears malpositioned within the posterior urethra”. R1’s gastrostomy tube was noted to be functioning well on evaluation by Nursing during the hospitalization.
The hospital records further documented R1’s primary diagnosis as "sepsis secondary to extended spectrum beta-lactamase (ESBL) Escherichia coli (E. coli) urinary tract infection." (E. coli produce an enzyme called ESBL which makes the E. coli harder to treat with antibiotics.) R1 also had secondary diagnoses that included dysphagia with gastrostomy tube, autism spectrum disorder, benign prostatic hyperplasia (noncancerous enlargement of the prostate gland) with chronic indwelling Foley catheter which appeared “malpositioned”, urethral erosion by catheter (tearing of the urethra), and a history of recurrent urinary tract infection (UTI). The hospital records also noted R1’s hygiene appeared poor as R1’s feet appeared unclean, however, document no apparent sign or symptoms of abuse.

On the allegation: “Staff failed to provide adequate care and supervision for a resident who uses a catheter” – The medical records confirm R1 had a history of urinary tract infections (UTI's). The facility staff stated they were instructed to only handle R1’s drainage bag by draining it of urine. Facility staff were instructed to not touch the catheter site that was connected to R1’s body. The medical records listed that the catheter appeared "malpositioned." Moreover, the CDC recommends that the catheter should not be replaced at fixed intervals, rather it should be replaced when infection is present, obstruction is present, or it is compromised. The home health nurse supervisor confirmed there were no documented signs of neglect by facility staff. The Department did not find sufficient evidence to support the allegation of staff neglecting the care of R1’s catheter. Therefore, the allegation “Staff failed to provide adequate care and supervision for a resident who uses a catheter” is deemed Unsubstantiated at this time.

On the allegation: “Staff are not providing appropriate care and supervision to the resident while in care of feeding tube” - During the Department’s interviews, facility staff stated they received no instruction to touch/clean around the PEG tube site that connects to R1’s body until after the 01/03/2024 hospitalization. In contrast, the home health nurse supervisor refuted this information and confirmed facility staff were instructed to clean around the PEG tube site. Report will continue on LIC9099-C (4TH PAGE).

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20240105155510

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JM'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 565850351
	VISIT DATE: 06/20/2024

NARRATIVE

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However, the home health nurse supervisor advised they did not observe any crust on R1’s PEG tube nor any documentation that suggested that crust forming in the PEG tube would occur. R1’s gastrostomy tube was noted to be functioning well on evaluation by Nursing during the 01/03/2024 hospitalization. The Department did not find sufficient evidence to support the allegation of staff neglecting the care of R1’s PEG tube. Therefore, the allegation “Staff are not providing appropriate care and supervision to the resident while in care of feeding tube” is deemed Unsubstantiated at this time.

On the allegation: “Staff do not ensure resident's personal hygiene needs are met” - The CMH medical record noted R1’s hygiene appeared poor as R1’s feet appeared unclean, however, the records document no apparent sign or symptoms of abuse. Interviews conducted with LRHH home health agency nurse supervisor noted that at each visit R1 was observed to be “clean and wasn't unkempt”, also noting there were no signs of neglect by facility staff. In addition, R1’s resident representative and TCRC did not have any concerns of staff neglect or abuse. The Department did not find sufficient evidence to support the allegation that the staff did not ensure R1’s personal hygiene needs were met. Therefore, the allegation “Staff do not ensure resident's personal hygiene needs are met” is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

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