567609939-6-9-2022-29-AS-KHEN-CFU263-20220628170629

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609939
Report Date: 06/08/2022
Date Signed: 06/09/2022 04:52:56 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
08/05/2020 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20200805152818

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: 4	DATE:	06/08/2022
		UNANNOUNCED	TIME BEGAN:	03:41 PM
MET WITH:	Allan Santos		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Staff neglect led to Resident #1 (R1) sustaining pressure injuries
Staff neglected to seek timely medical attention for Resident #1 (R1)

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver final findings for the above allegations. The initial visit was conducted on 08/06/2020 by LPA Kristin Heffernan and a subsequent visit was conducted on 03/18/2022 by LPA Camara. During today’s visit, LPA Camara met with House Manager Allan Santos and explained the reason for the visit.

On 08/05/2020, the Department received a complaint regarding allegations staff neglect led to Resident #1 (R1) sustaining pressure injuries while in care and facility staff did not seek timely medical attention for R1.

(continued on 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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 6

Control Number 29-AS-20200805152818

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: 06/08/2022

NARRATIVE

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On 08/06/2020, between 3:44 p.m. and 4:50 p.m., LPA Heffernan conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically with the Administrator Ivy Sudjati and House Manager Allan Santos. The LPA conducted an interview with the administrator at 3:44 p.m. and physical plant tour via FaceTime at 4:10 p.m. The LPA requested copies of pertinent documents relevant to the investigation and noted further investigation would be required.

On 09/18/2020, LPA Lyndia Sager was reassigned to this complaint investigation. On 12/04/2020 at 3:07 p.m. and on 12/08/2020 at 4:44 p.m. LPA Sager received pertinent records from the administrator. On 12/04/2020 at approximately 5:00 p.m., LPA Sager conducted a telephonic interview with a witness.

On 03/18/2022, LPA Camara conducted an unannounced subsequent complaint visit. LPA met with House Manager Allan Santos and spoke with Administrator Ivy Sudjati over the phone. During the visit, LPA conducted a brief physical plant tour at 3:49 p.m., interviewed the house manager at 3:52 p.m. and interviewed the administrator at 3:57 p.m. over the phone. The administrator was unable to meet LPA at the facility and R1’s records were located offsite. LPA requested the administrator provide any logs they may have kept regarding R1’s incontinence care and repositioning schedule. The administrator notified LPA she did not think they had such logs, but she would check. LPA noted further investigation was required.

On 03/21/2022, LPA Camara received an email from the administrator which stated they do not have any logs for the times staff repositioned R1 nor do they have logs regarding R1’s incontinence care. The administrator provided LPA Camara with documents she previously provided to LPA Sager.

(continued on 9099-C)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200805152818

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: 06/08/2022

NARRATIVE

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Information gathered throughout the investigation, reflects R1 was admitted to the facility, Grace Living 2, on 05/10/2020. Based on the Skilled Nursing Discharge Summary dated 05/09/2020, R1 was recovering from a hip fracture for which R1 received physical and occupational therapy. R1 continued receiving physical therapy at the facility from a home health agency. R1 was discharged from physical therapy on 07/14/2020. While at the facility, R1 developed pressure injuries on R1’s left and right coccyx on or about 06/11/2020. R1 received care for the pressure injuries from the home health agency (HHA) during the period 06/11/2020 – 07/13/2020. Staff were instructed by the HHA to reposition R1 every two hours and to only allow a supine position during R1’s meals. On 07/13/2020, the HHA indicated both pressure injuries had healed and the visits by HHA skilled nursing staff would cease. Facility staff were instructed to rotate R1’s position every two hours to ensure proper skin perfusion and avoid future injuries. Staff were also instructed to notify the HHA if a new pressure injury occurred.

On 07/23/2020, staff notified the administrator that R1’s coccyx pressure injuries had returned and needed skilled nursing care. Copies of texts provided by the administrator showed the administrator contacted the HHA on 07/23/2020 and requested they come back to the facility to provide pressure injury treatment. The HHA notified the administrator that R1’s insurance company had not approved them to provide further care for R1. On 07/24/2020, texts between the administrator and HHA showed the HHA representative sent an example of the type of pressure injury care supplies needed for R1. The administrator inquired if R1’s insurance company approved the HHA to return to the facility to provide care and the HHA informed the administrator they had not received approval yet; the HHA indicated approval can take days to weeks. On 07/30/2020, texts between the administrator and HHA representative showed the HHA was still awaiting approval from the insurance company and the administrator indicated R1’s pressure injuries were worsening and turning black. The HHA representative indicated the pressure injuries should have healed if staff were repositioning R1 every two hours as instructed. The HHA said R1 should only be in a supine position for meals. On 08/01/2020, texts showed the administrator notified the HHA representative that R1’s insurance company approved HHA pressure injury care. This was on a Saturday and the HHA informed the administrator the HHA on-call staff were notified, and she should also follow up with the HHA on Monday, 08/03/2020.

(continued on 9099-C)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200805152818

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: 06/08/2022

NARRATIVE

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In a text between the administrator and the house manager on 07/30/2020, the administrator informed the house manager that she called the HHA, but they still did not receive an order to provide care for the pressure injuries. The administrator said in the text a nurse informed her she could take R1 to the hospital emergency department, however R1’s Power of Attorney (POA) did not want her to do that out of COVID concerns. In addition, R1 was difficult to transport due to aggressive behaviors and would be difficult to manage in the hospital waiting area. The administrator instructed the house manager to have staff sit in R1’s room and do their best to distract R1 from turning into a supine position after being repositioned. On 08/01/2020, the house manager texted the administrator notifying her that R1’s pressure injuries were getting worse.

The HHA came to the facility on 08/03/2020 to assess R1’s pressure injuries. The pressure injuries were observed to have become one large pressure injury. The HHA nurse did not note the pressure injury stage, but did take a photograph and measured the pressure injury at 6 cm X 6 cm. The HHA nurse also photographed another pressure injury on R1’s right lower leg. An appointment with R1’s physician was made for 08/05/2020.

On 08/05/2020, R1 was transported to the medical appointment by a medical transportation service. R1’s physician sent R1 to the hospital due to the pressure injury on R1’s coccyx. R1 was admitted to the hospital on 08/05/2020 due to the Stage IV sacral decubitus ulcer with osteomyelitis and sepsis secondary to the sacral ulcer infection. On 08/07/2020, R1 had debridement of the sacral decubitus ulcer including sacral bone which measured 110 square centimeters. On 08/10/2020, R1 required another surgery for debridement of the sacrum ulcer including the bone measuring 25 square centimeters with laparoscopic sigmoid colostomy.

(continued on 9099-C)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20200805152818

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: 06/08/2022

NARRATIVE

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In regard to the allegation that staff neglect led to Resident #1 (R1) sustaining a pressure injury, during HHA visits to the facility to provide pressure injury care for R1 from 06/11/20 – 07/13/20, facility staff were instructed to reposition R1 frequently, at least every two hours, and not allow R1 to stay in a supine position. In addition, R1 suffered from bladder and bowel incontinence. There were no facility records to show staff had a schedule to frequently check R1 for incontinence care or repositioning. According to the HHA, R1’s pressure injuries should not have worsened if staff were ensuring proper repositioning. The administrator and staff failed to ensure R1 was provided proper incontinence care or repositioning to allow the area with healed pressure injuries to worsen to the point of a Stage IV sacral decubitus ulcer developing. Based on medical records and other documentation obtained and reviewed, the allegation is deemed Substantiated at this time.

For the allegation of staff neglected to seek timely medical attention for Resident #1 (R1), it was determined on or about 07/22/2020, the administrator and facility staff were aware R1’s coccyx pressure injuries had redeveloped and needed care by a skilled professional. On 07/24/2020, the HHA notified the administrator that insurance company approval for HHA pressure injury care could take days to weeks. Records show the administrator failed to seek other timely medical care by taking R1 to the hospital and allowed the pressure injuries to continue to worsen. R1 was not seen by the HHA nurse for 13 days and did not see a physician for 15 days after the pressure injuries were noticed, which was when R1 was finally sent to the hospital’s emergency department. Based on medical records and other documents obtained and reviewed, the allegation is deemed Substantiated at this time.

A $500 immediate civil penalty shall be assessed at a later date. Due to technical difficulties the LPA was unable to issue the civil penalty during today's visit. The 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 deficiencies are 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20200805152818

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/15/2022 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	§1569.312 Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2 This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the	1 2 3 4 5 6 7	Licensee will submit plan to provide a proper level of care and supervision to ensure resident needs are met. Submit to CCL by 06/15/2022.
	8 9 10 11 12 13 14	section cited above. Licensee failed to provide adequate care and supervision to R1 which attributed to R1 sustaining pressure injuries not reported and not properly cared for, 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). However, due to technical difficulties the penalty must be issued at a later date.
Type A 06/15/2022 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care	1 2 3 4 5 6 7	Licensee will submit plan to arrange for medical care when necessary to ensure resident needs are met. Submit to CCL by 06/15/2022.
	8 9 10 11 12 13 14	appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section cited above. Licensee failed to arrange for immediate and necessary care to R1’s pressure injuries resulting in R1’s pressure injuries worsening, which posed	8 9 10 11 12 13 14	an immediate health and safety risk to residents in care.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC9099 (FAS) - (06/04)

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