complaint·November 25, 2024

interviews on 02/27/2024, 03/15/2024, and 03/25/2024. Throughout the course of the investigation, LPA, IB Investigator and CCLD’s Program Clinical Consultant reviewed relevant documents for R1, including medical documents. A summary of documents reviewed and interviews conducted is as follows: Review of documents for R1 revealed that R1 had resided at this location since 12/31/2011 (formerly licensed as Royal Gardens of Camarillo). Physician’s reports were reviewed for the years 2020, 2021 and 2023. Physician’s report dated 06/17/2020 indicated “fall risk, [R1] recently moved to secure memory care unit on 06/16/2020 for close monitoring.” Physician’s report dated 03/24/2021 indicated R1 had motor impairment/paralysis, with a comment indicating “unsteady gait.” Physician’s report dated 03/09/2023 indicated R1 had a motor impairment/paralysis and assistive device was listed as walker, wheelchair. All physicians’ reports dated 2020 to present indicate R1 had a diagnosis of dementia and R1 required assistance with all activities of daily living except assistance with feeding. IB investigator requested copies of all incident reports related to R1 during the time they resided at the facility, however Administrator only provided 1 (one) report indicating R1 had previously fallen. Review of incident reports submitted to CCLD revealed an additional 2 (two) falls R1 sustained at the facility since operating as Aasta Assisted Living. Interviews with staff also revealed that R1 was “definitely becoming a fall risk” at the time of the incident on 12/28/2023. Incident report related to this complaint states that R1 was last checked on in their room at 6:00AM, when care staff assisted R1 with getting dressed. “Care staff went to [R1’s] room to remind [R1] it was breakfast time. When Ana walked in she saw [R1] laying face down in the middle of the room, she noticed blood on [R1’s] head and called medtech.” After interviews and document review, the following was then determined: Allegations: Neglect/Lack of supervision leading to questionable death & Neglect/Lack of supervision: facility employees failed to properly supervise resident resulting in an unwitnessed fall and multiple injuries to the resident: The complaint alleges the facility employees failed to provide an appropriate level of supervision, which resulted in R1 falling, hitting their head causing periorbital fractures as well as a brain hemorrhage. Complaint alleges R1 died in the hospital several days later as a result of the injuries sustained in the fall. Incident report reviewed indicated staff found R1 on the floor of their room around 06:30AM on 12/28/2023. Internal incident report indicates R1 had last been observed by staff at 06:00AM, when care staff assisted R1 Report Continued on LIC 9099-C (p.3) with dressing. Interview revealed that both documents were originally authored by staff that had initially found R1 after the fall and included additional details, but were rewritten inaccurately by another staff. LPA observed that the incident report indicates R1’s right side of their face was affected, however hospital documents indicate injuries were sustained on R1’s left side. Interview revealed that although R1’s annual physician’s reports and care assessments indicated R1 required a full assist with all personal grooming and hygiene needs, care staff reported regularly leaving R1 in their room unsupervised to brush their own hair and wash their own face. Additionally, physician’s report dated 03/24/2021 indicated R1 is “at risk if allowed direct access to personal grooming and hygiene items” yet care staff allowed R1 access to said items unsupervised to complete their own ADL care. Staff interviews revealed that as expected as R1 was aging and due to R1’s overall medical condition including their diagnosis of dementia, R1 was becoming less capable of completing tasks independently and R1 regularly forgot to use their walker, which made R1 a fall risk. In spite of documentation on both R1’s care assessment and R1’s physician’s reports indicating R1 requires a full assist with ADL care (except feeding,) on 12/28/2023, care staff left R1 in their room to complete personal hygiene and grooming tasks without any required staff assistance or supervision. Additionally, staff interviewed were aware R1 did require transfer assistance “at times” and that R1 needed regular verbal reminders to use their walker, staff did not return to R1’s room to assist R1 prior to breakfast time. Staff did realize around 06:30AM that R1’s roommate was present in the dining room and R1 wasn’t present as expected, so care staff went to R1’s room to check on them and found R1 in their room, face down on the floor with blood pooling by R1’s head. Med tech then assessed R1 and dialed 9-1-1 for further medical assistance. Medical documentation for R1 revealed R1 was taken to Saint John’s Pleasant Valley Hospital Emergency Department (in Camarillo) via ambulance. R1 had a significant laceration and soft tissue swelling on the left side of their face in the periorbital area and R1 was transferred to the Saint John’s Regional Medical Center (in Oxnard) direct observation unit for further management. CT head scan showed left frontal subarachnoid hemorrhage (bleeding from a damaged blood vessel), 3mm small left subdural hematoma, left zygomatic arch fractures. CT maxillofacial showed nondisplaced fracture involving the lateral aspect of the left orbit posterior inferior left maxillary sinus mildly displaced fracture with soft tissue within the left maxillary sinus likely representing hemorrhage, buckling type fracture involving the left zygomatic Orange. The resident was admitted to the hospital. R1 was admitted to the Direct Observation Unit (DOU) and had neuro checks every 2 hours as per unit protocol. Prior to the fall, R1’s physician’s report indicated R1 had no concerns Report Continued on LIC 9099-C (p.3) swallowing and R1 could self-feed. However, while in the hospital DOU, R1 experienced dysphagia on 12/29/2023 and failed swallow evaluations on 12/30/2023 and 12/31/2023. On 12/30/2023, a neurology consultation was conducted, and it was determined that R1 had a traumatic intracranial hemorrhage, facial fracture, status post-fall. On 01/01/2024, R1 experienced respiratory distress and with the development of tachycardia, the medical team discussed comfort care with R1’s responsible party. R1 was placed on palliative care and subsequently passed away in the hospital on 01/04/2024. Certificate of death listed sequelae of subdural and subarachnoid hemorrhage and blunt head trauma as the immediate cause of death. Coroner indicated the ground level fall took place on 12/28/2023 at approximately 06:15AM was the cause of the injury related to R1’s death. Based on interview and record review, the preponderance of evidence standard has been met, therefore the allegations “neglect/lack of supervision leading to questionable death” and “neglect/lack of supervision: facility employees failed to properly supervise resident resulting in an unwitnessed fall and multiple injuries to the resident” are deemed SUBSTANTIATED at this time. Allegation: Licensee did not meet resident’s ADL needs: All of R1’s annual physician’s reports dated 2021 – 2023 indicate R1 is unable to meet their own ADL needs and required assistance with the following: bathing, dressing/grooming, caring for toileting needs, and assistance with managing cash resources. R1’s care assessment dated 03/01/2023 also indicated R1 required “full assistance” with grooming and hygiene as well as dressing. This same care assessment indicated R1 used a walker for mobility and that R1 required transfer assistance “at times.” However, interview revealed that on the morning of 12/28/2023, staff went into R1’s room sometime between 05:30AM and 06:00AM and assisted R1 in getting dressed, but that staff had left R1 unsupervised in their room to comb their own hair and wash their own face. Staff stated they expected R1 to complete their own ADL care before walking themselves to the dining room. Both R1’s physician’s report dated 03/09/2023 as well as care assessment dated 03/01/2023 indicated R1 required full assistance with personal grooming and hygiene. Additionally, staff interviewed indicated that R1 used to be more independent but over time, has needed more assistance. Care staff admitted to not providing the ADL care outlined in R1’s care assessment, as they only provided assistance with dressing R1 and allowed R1 to complete additional ADL tasks without assistance or supervision, although R1 required full assistance with these activities. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the allegation “Licensee did not meet resident’s care needs” is deemed SUBSTANTIATED at this time. Report Continued on LIC 9099-C (p.4) Allegation: Licensee did not provide resident’s responsible party an updated care plan: LPA reviewed care plans for R1, as well as conducted interviews with management and other facility staff. LPA also spoke with R1’s responsible party. R1’s responsible party stated they had not received a copy of R1’s care plan, nor had R1’s care plan been reviewed with R1’s responsible party. R1’s responsible party stated they “assumed that staff were assisting a 93 year old with dressing and personal care needs,” but stated they were never provided with a document specifying what ADL care was being provided to R1. Staff interviewed indicate they conduct care assessments every 6 (six) months on all residents, but that these are not reviewed with the residents nor their responsible parties. Care assessments reviewed for R1 did not contain a signature line to indicate the resident nor their responsible party had reviewed the document. The facility does not utilize the form Community Care Licensing Division (CCLD) provides on the Department website which does include a signature line, but instead the Licensee uses and in-house form. Facility Management was unable to provide written proof that a current care plan was provided to R1’s responsible party. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the allegation “Licensee did not provide resident’s responsible party an updated care plan” is deemed SUBSTANTIATED at this time. Allegation: Licensee did not comply with reporting requirements: The complaint alleges that R1’s responsible party was not informed either verbally nor in writing of the incident that occurred on 12/28/2023. Interview with R1’s responsible party revealed that they were out of town at the time of R1’s incident. R1’s responsible party indicated that they received a voicemail from the hospital on 12/29/2023, but that no voicemail nor missed call was received on their cell phone from the facility phone number or any other phone number possibly related to the facility. R1’s family member called the facility on 12/29/2023 to inquire about R1’s status, but the front desk staff could only confirm that R1 had been sent to the hospital but did not have any other details as to R1’s status and neither the med tech nor the Administrator were available at that time to speak with R1’s family member. The med tech did call R1’s responsible party back later that day. The med tech on duty at the time of the fall reported to CCL and to R1’s responsible party that they did not leave a message for R1’s responsible party. Med tech indicated they left a message for another one of R1’s family members, however, could not recall time the call was made nor whether the call was made using the facility telephone or the staff’s personal cell phone. Med tech did not allow LPA to review the call log on their personal cell phone, so LPA was unable to confirm whether either of the calls to R1’s family had been made. R1’s responsible party stated they spoke to the other family member Report Continued on LIC 9099-C (p.5) and this person also had not received a missed call nor message from facility staff. Additionally, staff interviewed indicated although they did write an incident report related to R1’s fall and subsequent hospitalization, the written document was not provided to R1’s family member. Staff interviewed stated they do not provide a written report to any resident’s responsible party unless it is requested. Based on interview and record review, the preponderance of evidence standard has been, therefore the allegation “Licensee did not comply with reporting requirements” is deemed SUBSTANTIATED at this time. A $1000 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies are cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.