complaint·September 26, 2024

The investigation confirmed that the individual in question was not listed in the facility's clearance records. They did not possess the required background checks or clearance as an employee. The staff interviewed corroborated that the individual had been present in the facility without the proper clearance. The allegation that an uncleared adult was an employee within the facility is substantiated as there is a preponderance of evidence to prove the alleged violation occurred. The individual was hired as a caregiver without the necessary background checks and approvals, which is a violation of Health and Safety Code section 1569.17 (e )(1). An exit interview was conducted; a copy of this report along with Licensee Appeal Rights LIC 9058 (REV 3/22) were provided to Art Vinarao, Caregiver and his signature confirms receipt of these documents. On October 26, 2020, hospice staff documented wounds, of unknown staging, to R1’s forearm and coccyx. On November 25, 2020, hospice staff documented R1 was noted to have developed a stage 3 pressure injury. Interviews with outside medical professionals who visited the facility and observed R1 did not have concerns regarding neglect or unmet needs for R1. Additionally, there were no concerns regarding assistance with medication administration or mismanagement of R1’s medication. R1 passed away at the facility on November 26, 2020. According to the County of San Diego Certificate of Death, R1’s cause of death was listed as Cardiac Arrest and Respiratory Arrest with Hepatic failure, unspecified without coma, and Non-Alcoholic Cirrhosis of Liver noted as the underlying causes of death. A review of records revealed R2 was non-ambulatory and required assistance with bathing, dressing, feeding, transferring, and incontinence care. R2 was able to communicate their needs. R2 began receiving hospice services from a hospice agency before their admission to the facility. Interviews with staff indicated staff checked on R2 approximately every two hours to assist with repositioning and assisted R2 with incontinence care. R2 was prescribed oxygen due to their medical condition. Interviews with medical professionals revealed R2 was oriented and able to operate their oxygen machine. Interviews with outside sources and outside medical professionals who visited the facility and observed R2 did not have concerns regarding neglect or unmet needs for R2. Additionally, there were no concerns regarding assistance with medication administration or mismanagement of R2’s medication. R2 passed away at the facility on October 3, 2020. R2’s cause of death was listed as Interstitial Lung Disease. Outside source and residents interviewed regarding the language barrier, there are no concerns, and staff could communicate with residents in their preferred language. Based on the investigation findings, the allegations made against the staff regarding all allegations of Questionable Deaths, Staff Mismanagement of Residents' Medications, Staff Failure to Meet Residents' Needs, Untrained staff, and Staff Unable to Communicate with Residents Due to a Language Barrier—are unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Art Vinarao, Caregiver. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Caregiver and his signature on this report confirms receipt of the Licensee Rights.