complaint·April 30, 2024

LPA obtained resident roster and names of staff. LPA asked facility for LIC500, and facility staff stated they would email it later today. LPA interviewed four staff (S#1- S#4), six residents (R#1-R#6) and two witnesses (W#1-W#2). Allegation: Staff did not prevent resident from sustaining severe fractures while in care. It is alleged that resident sustained fractures while in care due to facility Neglect/Lack of Care and Supervision. The investigation revealed: LPA Interviewed four (4) staff S1-S4 and four (4) of four (4) staff denied the allegations. LPA interviewed six (6) residents R1-R6 and six (6) of six (6) residents could not collaborate the allegation. Administrator denied that facility caused fractures, and three (3) of three (3) staff stated they were unaware that resident had facial fractures. According to Department interviews, and records reviewed, resident was admitted to facility on 05/01/2022. On 11/26/2022, resident was found to be lethargic and unresponsive. Facility called 911 and the resident was transported to Pomona Valley Hospital. At the hospital, evidence of facial fractures (Right orbital lateral wall fracture, right zygomatic arch fracture) was documented on hospital records for admission date of 11/26/2022. Based on supporting evidence, facility failed to provide proper medical attention, and the facility provided inadequate care and supervision that caused unexplained injuries while under care and supervision of the facility. There is sufficient evidence to substantiate this allegation. Allegation: Staff did not prevent resident from sustaining pressure injuries. It is alleged that staff did not prevent resident from sustaining pressure injuries while in care. The investigation revealed the following, LPA Interviewed four (4) staff S1-S4 and four (4) of four (4) staff denied the allegation. LPA interviewed six (6) residents R1-R6 and six (6) of six (6) residents could not collaborate the allegation. Administrator denied that resident developed pressure injury while at the facility. Administrator stated that resident arrived at facility with pressure injuries. (CONTINUED) According to Department interviews, and records reviewed, resident was admitted to facility from nursing home on 05/01/2022. Discharge paperwork from the nursing home documents a stage 1 pressure injury on each heel and sacrococcyx blanchable redness. Administrator agreed that resident arrived to the facility as described by the nursing home discharge paperwork. Resident was found to be lethargic and unresponsive on 11/26/2022. Facility called 911, and the resident was transported to Pomona Valley Hospital. While at the hospital, RN documented wound on resident’s buttock midline coccyx: 6cm x 6cm x 0cm (wound had no documented staging, photograph showed area to be redden, not open). RN also documented right foot wound with no documented staging. There was no mention of the left foot in the hospital records. Additional RN staff documented that resident had a “closed stage 3 pressure injury on coccyx and evidence of scar tissue”. Due to facility failing to provide proper care and supervision, resident’s pressure injury on coccyx progressed from blanchable redness to stage 3 during her stay at facility. There is sufficient evidence to substantiate this allegation. The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, and Chapter 8 are cited on the attached LIC 9099D. An immediate $500 civil penalty is being issued during today's visit due to the neglect/lack of care and supervision resulting in resident sustaining fractures to face. An exit interview was conducted with the Administrator Toby Miclat and a hard copy of licensing report was provided along with appeal rights. . LPA obtained resident roster and names of staff. LPA asked facility for LIC500, and facility staff stated they would email it later today. On 08/08/2023 LPA Alberto Lopez made a subsequent visit to facility and met with Administrator Toby Miclat and discussed the purpose of the visit. LPA took a tour of the living room, dining areas, kitchen, common areas, and random resident rooms. LPA did not observe any signs of neglect, abuse or other immediate health and safety risks. LPA requested copies of staff and resident roster, and interviewed four(4) Staff (S#1-S#4) and six (6)residents (R#1-R#6). LPA interviewed four staff (S#1- S#4), six residents (R#1-R#6) and two witnesses (W#1-W#2). Allegation: Staff did not meet residents hygiene needs. It is alleged that facility failed to provide resident with adequate hygiene needs The investigation revealed, LPA interviewed four (4) staff S1-S4 and four (4) of four (4) staff denied the allegation. W1 and W2, who are family members, stated resident had a bad body odor. LPA interviewed six (6) residents R1-R6 and six (6) of six (6) residents could not collaborate the allegation. Administrator denied that facility did not meet resident hygiene needs, and three (3) of three (3) staff stated they provide all residents with proper hygiene needs daily. LPA toured all rooms, all residents were clean, bed linens were clean, and the rooms were free of odors. There is not enough evidence to support this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and copy of report provided to Administrator Toby Miclat