300612904-7-12-2023-22-AS-SSAS-CULUU6-20230811155302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300612904
Report Date: 07/12/2023
Date Signed: 07/12/2023 09:44:00 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2021 and conducted by Evaluator Lydia Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210625161221

FACILITY NAME:	ADELINE GUEST HOME		FACILITY NUMBER:	300612904
ADMINISTRATOR:	ADELINA MONCERA		FACILITY TYPE:	740
ADDRESS:	741 N. EAST STREET		TELEPHONE:	(714) 996-0568
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY:	6	CENSUS: 3	DATE:	07/12/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Alexandrea "Alex" Pacleb		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident developed Stage 4 pressure injury while in care
Facility did not follow the Admission Agreement
Staff coerced Resident’s representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lydia Martinez conducted and unannounced visit to the facility to deliver findings on the above allegations. LPA identified herself and discussed the purpose of the visit with Caregiver Alexandrea "Alex" Pacleb. The complaint was investigated by the Department. Administrator Adeline Moncera or Administrator Janice Jabonero were not available for today's visit. Cargeiver Pacleb and one Resident were present during today's visit. The other two Residents are in the hospital.

During the investigation, interviews were conducted with facility Administrator and witnesses. Additionally, copies of facility file for Resident 1 (R1), photos, Unique Hospice and Palliative care records, Omni Wound Physicians records, and Vitas Healthcare records were obtained and reviewed.

Witness 1 (W1) was caring for R1 in her home from 7/15/2020 to 2/25/2021. Services were approved from Unique Hospice and Palliative Care, Inc. from 8/25/2020 – 3/15/2021. Wound care was provided by Unique Hospice and Omni Wound Physicians.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

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 22-AS-20210625161221

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADELINE GUEST HOME	FACILITY NUMBER: 300612904
	VISIT DATE: 07/12/2023

NARRATIVE

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Based on records reviewed, a visit on 2/20/2021 from Unique Hospice staff showed wounds to the Coccyx (stage IV - chronic) and iliac Crest (stage III – chronic). R1 was assessed at W1’s home prior to transferring her to Adeline Guest Home on 2/25/2021. RN Sandy Cheng documented R1’s wounds at W1’s home as: "unstageable to right buttock, wound to ischium appears necrotic with areas of active bleeding". R1 was at Adeline Guest home from 2/25/2021 – 5/15/2021. VITAS Hospice took over hospice care from 3/15/2021 – 5/15/2021; including wound care. Wounds to be treated: "coccyx (stage IV); above sacrum (stage III); inner right thumb (stage IV); BIL heels (stage I); tarsal of right foot, lateral right foot, inner left foot, upper achilles heal (all at stage 1); and right ear (stage II)".

W1 stated during the interview that R1’s pressure wounds were all healed prior to R1’s placement at Adeline Guest home. W1 provided photographs to document R1’s wounds prior and after placement. When asked to meet with W1 to verify the date of the photographs W1 has provided, W1 refused to meet with IB Investigator and ended the phone call. W1 continued to share the same information including timeline of the events along with photographs that are not time stamped.

Regie Banggalat (Administrator) provided R1’s Physician’s Report (signed on 2/25/2021). Doctor Lopez documented R1 required a hospital bed, oxygen, a Hoyer lift, and repositioning; Coccyx pressure ulcer stage IV; and receiving hospice care. Administrator Banggalat received written instructions from Unique Hospice and VITAS nurses “not to touch the wounds”, “don’t open the bandages”, “turning R1 every two hours, and to call when condition changes”. Administrator Banggalat stated she did not observe any of R1’s pressure wounds because the wounds were always covered up with bandages.

Hospice records showed R1 had multiple pressure wounds (stage IV/unstageable) prior to moving into the facility. Wound care was provided and monitored by Unique Hospice, Omni Wound Physicians, and Vitas.

It was alleged that facility did not follow the admission agreement and that staff coerced resident’s representative. R1 moved into the facility on 02/25/2021. Interviews were conducted with Administrator Banggalat and Witness 1. Administrator Banggalat reported she provided W1 with a copy of the Admission Agreement for her review and signature. Administrator stated W1 refused to sign and return it.

(cont LIC809C)

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20210625161221

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ADELINE GUEST HOME	FACILITY NUMBER: 300612904
	VISIT DATE: 07/12/2023

NARRATIVE

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Administrator Banggalat provided LPA Martinez with a copy of the facility Admission Agreement which she stated is the same one she provided W1. Interview with W1, stated Administrator was trying to force W1 to agree to a contract W1 never agreed to. W1 could not elaborate on the details during the interview. W1 stated she threw it out. W1 stated there was a verbal agreement which was scribbled on a piece of paper which W1 did not have. Administrator stated she only provided the Admission Agreement to W1. W1 stated she was given an ultimatum that if W1 did not sign the Admission Agreement W1 would have to move R1. W1 stated she refused to sign the fake 35 page contract. W1 stated R1 was moved out.

Based on the information gathered during the investigation and interviews conducted, the Department is unable to ascertain if the allegations of Resident developed Stage 4 pressure injury while in care, Facility did not follow the Admission Agreement and Staff coerced Resident’s representative occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated.

An exit interview was conducted and a copy of this report was sent to email on file.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

LIC9099 (FAS) - (06/04)

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