567609939-3-10-2022-29-AS-KHEN-CCXRV5-20220328132059

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609939
Report Date: 03/09/2022
Date Signed: 03/10/2022 08:57:51 AM

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
05/19/2021 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20210519135621

FACILITY NAME:	GRACE LIVING 2		FACILITY NUMBER:	567609939
ADMINISTRATOR:	SUDJATI, IVY		FACILITY TYPE:	740
ADDRESS:	46 CARRIAGE SQUARE		TELEPHONE:	(310) 562-8250
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY:	6	CENSUS: 5	DATE:	03/09/2022
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Allan Santos		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

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Resident sustained multiple injuries while in care.
Facility did not provide food and/or liquid in the quality or quantity necessary to meet resident's needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations. The initial complaint visit was conducted on 05/19/2021 by LPAs Angel Ascencio and Zabel Chochian. During today’s visit, LPA Ascencio met with Allan Santos and explained the reason for the visit.

On 05/19/2021, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that Resident #1 (R1) sustained multiple pressure injuries while in care and the facility did not provide food in the quality or quantity necessary to meet R1’s needs. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Lorraine Patterson.

Continued on LIC 9099 - C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

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-20210519135621

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: GRACE LIVING 2	FACILITY NUMBER: 567609939
	VISIT DATE: 03/09/2022

NARRATIVE

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On 05/19/2021, at 2:09pm, LPAs Ascencio and Chochian conducted the initial complaint visit and met with Ivy Sudjati, Administrator. Between 2:09pm and 3:40pm, the LPAs toured the facility with the Administrator, reviewed resident records, interviewed the Administrator, and obtained copies of pertinent documents relevant to the investigation. The LPAs informed the Administrator that the complaint allegations required further investigation and the complaint was forwarded to the Investigations Branch (IB) for review.

Investigator Patterson conducted interviews with the reporting party on 06/15/2021, at approximately 10:37am; with facility staff and residents on 10/26/2021, from approximately 1:48pm to 3:13pm; with Licensee/Administrator on 10/27/2021, at approximately 9:56am; and with Mission Hospice on 11/01/2021, at approximately 2:07pm. Investigator Patterson was unable to contact R1’s Gastroenterologist, despite multiple attempts.

Information obtained through interviews revealed that R1’s representative, who was the durable power of attorney, refused the standardized tube feeding formula and made their own formula using unpasteurized raw cashews, almonds, sunflower seeds, and fruits to blend liquids and food for R1. R1 had a G-tube and had difficulty swallowing and the G-tube was needed for nutrition. R1 was immunocompromised and at a higher risk for food borne illness and the use of unpasteurized food put R1 at a higher risk and was not recommended. R1 had been frequently hospitalized for inadequate nutrition. R1’s representative was adamant on this type of feeding and required the facility to provide the blends created. R1’s representative was resistant to nutrition education. R1 had lost weight on this nutrition plan and continued to have severe malnutrition.

Investigator Patterson reviewed documents including R1’s facility file, advance medical directives, communication emails between specialists, and medical/hospice/palliative records. Per R1’s Physician Report dated 12/29/2020, the primary diagnosis was listed as Dysphagia with chronic g-tubes. R1’s special diet was listed as administration of tube feeds, Kate Farm, bolus feeding, dysphagia diet. R1’s secondary diagnosis was listed as Hypertension and PAFIB. The report also listed R1 had a history of skin breakdown, was non-ambulatory and bedridden due to physical condition. R1’s illness also included fragility and poor nutrition; physical health status was fair; and R1 required home health physical and occupational therapy.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210519135621

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: GRACE LIVING 2	FACILITY NUMBER: 567609939
	VISIT DATE: 03/09/2022

NARRATIVE

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Mission Hospice records listed the hospice certification and plan of care certification period for R1 as 03/20/2021 through 05/28/2021. R1 was admitted to hospice for End Stage Heart Disease. Nutritional requirements of the plan stated nothing by mouth, puree fruit through G-tube only as tolerated. The Kate Farms standard formula G-tube feedings were recommended, ordered and attempted, however, R1’s dysphagia worsened. R1’s representative insisted R1 try to eat fruits and nuts. The hospice Dr. agreed with the family’s request and it was approved that R1’s food be liquified into the G-tube based on but not limited to R1 not being able to tolerate anything else.

The St. John’s Regional Medical Center (SJRMC) medical records revealed R1 was admitted to the ER on 04/17/2021 due to low blood pressure. R1 was discharged with diagnosis of Hypokalemia, Endophthalmitis and transferred to UCLA. While at UCLA, R1 had a speech therapy assessment. R1 was noted as too lethargic for oral intake and posed a high risk for aspiration. The speech therapist contacted the Dr. who requested R1 receive nothing by mouth or via tube until electrolytes balanced out. Additionally, the Dr. requested that R1’s representative bring in the tube feeding formula for R1 and not a homemade smoothie. On 04/18/2021, it was noted R1 had blanchable redness on coccyx present on admission along with a skin tear to upper thigh. R1’s discharge diagnosis was septic shock; urinary tract infection; hypovolemic hyponatremia; hypokalemia; hypophosphatemia; dehydration; toxic metabolic encephalopathy and severe protein calorie malnutrition.

R1 was admitted again to SJRMC on 05/15/2021 with a chief complaint of abdominal pain. During the exam, R1 was noted to have a pressure injury on sacrum and heels, unstageable Upon evaluation, R1 had a high probability of imminent or life-threatening deterioration. R1 was assessed Code Blue and CPR given. All medical professionals in the room agreed to stop the code and stated no further ideas for intervention. R1 died on 05/16/2021 at 7:32pm with the preliminary cause of death as septic shock, urinary tract infection. There were no abuse or neglect concerns noted in the emergency department records.

Continued on LIC 9099 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20210519135621

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: GRACE LIVING 2	FACILITY NUMBER: 567609939
	VISIT DATE: 03/09/2022

NARRATIVE

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On the allegation: Neglect/Lack of Care and Supervision - Facility did not provide food in the quality or quantity necessary to meet Resident #1 (R1) needs. Investigator Patterson obtained and reviewed medical/hospice/palliative records and the facility file for R1. In addition, Investigator Patterson interviewed staff, residents, hospice, and medical professionals. R1 was admitted to the hospital on 05/15/2021 with a diagnosis not limited to dehydration and severe protein calorie malnutrition and R1’s representative was adamant with providing R1 with homemade blends over a standardized tube feeding which was not recommended. R1’s representative required the facility staff to feed R1 home blends which placed R1 at a higher risk for food borne illness due to R1 was immunocompromised. R1 had a terminal diagnosis of 6 months or less. R1 was prescribed nothing by mouth (NPO), suffered severe food allergies, poor nutrition and hydration. R1 was only able to tolerate limited foods. R1 was a full code. R1 was on and off hospice and palliative care when aggressive/elective care was needed. R1’s representative was the durable power of attorney and guided the family towards aging and R1’s diet. Facility staff reported the care provided R1 was congruent to the plan of care and as doctors recommended. The information and evidence obtained during the investigation did not sufficiently support the allegation, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, and copy of report given provided to Admin via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

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