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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601976
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:26:36 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/18/2023 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230418110249
FACILITY NAME:DEL MAR PARKFACILITY NUMBER:
198601976
ADMINISTRATOR:DENISE SUTTONFACILITY TYPE:
740
ADDRESS:990 EAST DEL MAR BOULEVARDTELEPHONE:
(626) 577-0215
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:60CENSUS: 54DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Denise Sutton, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility meals do not meet the needs of the resident(s).
Resident's bathroom is in disrepair.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations. The purpose of the visit was discussed with Denise Sutton.

The investigation consisted of the following: On 4/27/2023, LPA conducted a physical plant tour of the facility with focus on room #202 and the kitchen. Staff (S1- S3) were interviewed. LPA reviewed resident (R1's) file and obtained copies of file documents [Face Sheet, Physician Report, Admission Agreement, Resident Appraisal, hospital discharge documents, resident notes, Medication Administration Record (MAR), physician orders, weekly [ Sun. April 19- April15] food menu, special diet menu, alternate food menu, resident service plan, and staff and resident rosters. On 4/28/2023, resident (R1) was interviewed at their new place of residence. During today's visit, a physical plant tour was conducted with focus on 7 resident room bathrooms and kitchen food service. Residents (R2 - R8) and staff (S4) were interviewed. Copies of 3 three incident reports 4/15/23 and two (2) dated 4/24/23 were reviewed and obtained.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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 5
Control Number 28-AS-20230418110249
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DEL MAR PARK
FACILITY NUMBER: 198601976
VISIT DATE: 10/20/2023
NARRATIVE
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Allegation: Facility meals do not meet the needs of the resident(s). It is alleged that resident (R1's) physician ordered restricted diet is not meeting the resident's nutritional needs because residents are served very small meal portions, the food is of low quality with no vegetables, and all the food appears processed. According to information obtained, resident (R1) has physician orders for a diabetic diet. A total of eight (8) residents were interviewed, of which one (1) resident stated the food served is not meeting their needs.
The facility serves open breakfast meal. Lunch and dinner are set menus. There is an alternate menu as well. Snacks are served and health shakes are served four (4) times a day in addition to their meals for residents that are low weight. A total of four (4) staff were interviewed, it was acknowledged that resident (R1's) Physician's Report stated the resident requires a Diabetic diet, but the resident was not placed on the restricted diabetic diet due to an oversight. Per record review, the findings indicate that resident (R1) has not added to the Specialized Diet list during the time the resident resided at the facility.

Allegation: Resident's bathroom is in disrepair. It is alleged that the screws of the stainless steel grab bar in resident (R1's) the bathroom tub area were loose. The resident tried to stabilize their self upon exiting the shower chair and the resident fell back and almost hit their head, but no injuries were sustained. According to reporting party, Administrator was informed of the hazard, but it was not fixed for at least 3 days. Staff interviews revealed that when resident (R1) moved in the room was checked. It is unknown if the grab bar became loose after resident use, or whether it was a staff oversight when they completed the Apartment Safety and Cleanliness inspection. According to Administrator, preventative maintenance on resident rooms is done on a quarterly basis. LPA inspected eight (8) rooms, none had loose bathroom grab bars. A total of eight (8) residents were interviewed, only resident (R1) reported loose grab bars. Based on observation and interviews conducted, the findings indicate that resident (R1's) bathroom had loose grab bars likely due to staff oversight during the move-in activity, but staff reported it was not intentional. The grab bar was repaired on 4/25/2023.

Based on record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited. See LIC 9099D.

An exit interview was conducted and a copy of this report and appeal rights was provided to Administrator Denise Sutton.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230418110249
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DEL MAR PARK
FACILITY NUMBER: 198601976
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2023
Section Cited
CCR
87555(b)(7)
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General Food Service Requirements. Modified diets prescribed by a resident’s physician as a medical necessity shall be provided.

This requirement was not met evidenced by:
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Administrator shall ensure all resident files with special diet physician orders are communicated with kitchen and LVN staff.

Submit a written plan of correction by POC due date.
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Based on record review, resident (R1's) Physician's Report states the resident requires a diabetic diet. However, R1 was not being served a diabetic diet, and had not been added to the restricted diet list; which poses a potential health and safety risk to persons in care.
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Type B
11/03/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met evidenced by:
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Administrator shall submit a written plan of correction by POC due date.
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Based on interviews conducted, resident (R1's) bathroom grab bars were loose and not fixed in a timely manner, which poses a potential health and safety risk to persons in care.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/18/2023 and conducted by Evaluator Noemi Galarza
COMPLAINT CONTROL NUMBER: 28-AS-20230418110249

FACILITY NAME:DEL MAR PARKFACILITY NUMBER:
198601976
ADMINISTRATOR:DENISE SUTTONFACILITY TYPE:
740
ADDRESS:990 EAST DEL MAR BOULEVARDTELEPHONE:
(626) 577-0215
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:60CENSUS: 54DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Denise Sutton, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not dispense resident's medications as prescribed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations. The purpose of the visit was discussed with Denise Sutton.

The investigation consisted of the following: On 4/27/2023, LPA conducted a physical plant tour of the facility with focus on room #202 and the kitchen. Staff (S1- S3) were interviewed. LPA reviewed resident (R1's) file and obtained copies of file documents [Face Sheet, Physician Report, Admission Agreement, Resident Appraisal, hospital discharge documents, resident notes, Medication Administration Record (MAR), physician orders, weekly [ Sun. April 19- April15] food menu, special diet menu, alternate food menu, resident service plan, and staff and resident rosters. On 4/28/2023, resident (R1) was interviewed at their new place of residence. During today's visit, a physical plant tour was conducted with focus on 7 resident room bathrooms and kitchen food service. Residents (R2 - R8) and staff (S4) were interviewed. Copies of 3 three incident reports 4/15/23 and two (2) dated 4/24/23 were reviewed and obtained.
***See next page.****
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230418110249
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DEL MAR PARK
FACILITY NUMBER: 198601976
VISIT DATE: 10/20/2023
NARRATIVE
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Allegation: Facility staff did not dispense resident's medications as prescribed. It is alleged that on 4/18/2023, resident (R1's) PRN "Hydrocodone-Acetamin 5-325 mg medication was not administered per physician order i.e. every six (6) hours as needed because the medication was brought to the resident at 3:00 AM instead of 2:00 AM, which resulted in "suffering". According to information provided, the resident was being given the PRN medication, but on at least two (2) other occasions it was late as well. Resident (R1) stated that the medication was to be administered routinely every 6 hours. A total of eight (8) residents were interviewed, of which one (1) stated that their medications are not dispensed as prescribed. Per staff interviews, the PRN medication was to be administered every 6 hours. The medication order was not changed by Dr. Chen until 4/20/2023. The new physician's order was changed to every four (4) hours routinely, "hold if pt is asleep". Per record review of Narcotic Drug Record and Medication Administration Records, it was noted that the PRN "Hydrocodone-Acetamin 5-325 mg medications was not always administered every 6 hours. However, based on record review of physician's orders the medication was changed to every 4 hours routinely until 4/20/2023. Therefore, facility staff followed physician's orders.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Denise Sutton. A copy of this report was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5