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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607689
Report Date: 10/20/2022
Date Signed: 10/20/2022 10:12:13 AM

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 DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2021 and conducted by Evaluator Ana Soto
COMPLAINT CONTROL NUMBER: 11-AS-20210921093903
FACILITY NAME:AMERICARE ASSISTED LIVING OF ROLLING HILLSFACILITY NUMBER:
197607689
ADMINISTRATOR:EDNA DIMALANTAFACILITY TYPE:
740
ADDRESS:4826 ROCKBLUFF DR.TELEPHONE:
(310) 422-5364
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY:6CENSUS: 5DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Norberto Batongbakal, House ManagerTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident developed multiple pressure injuries while in care.
Resident sustained a fracture while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent investigation visit to deliver decisions and findings for the allegations listed above. LPA met with Norberto Batongbakal, House Manager and the purpose of the visit was explained.

The investigation consisted of the following: Licensing Program Analyst (LPA) Ulysses Coronel initiated the complaint and obtained copies of staff and resident records The complaint was referred the Department of Social Services Investigation Branch and was assigned to Investigator (IB) Dennis Seng. Investigator Seng conducted record review, review of medical records and conducted staff, resident and witness interviews.

The investigation revealed the following:
Regarding the allegation “Resident developed multiple pressure injuries while in care.” Record reviews conducted by IB indicate that 08/12/2021 R1 was given a body check during hospital discharge and no pressure injuries were observed on R1’s body.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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 11-AS-20210921093903
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMERICARE ASSISTED LIVING OF ROLLING HILLS
FACILITY NUMBER: 197607689
VISIT DATE: 10/20/2022
NARRATIVE
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Record reviews also indicate that 09/17/2021 during hospital admission, R1 was observed with an Unstageable Pressure Injury to the Let Hip / Greater Trochanter ~7.5 x 6 x 0 cm, a Stage 3 Pressure Injury to the Sacrum extending to right buttock ~6 x 6 x 0.1 cm, a Stage 2 Pressure Injury on the Left Buttock ~2 x 3 x 0 cm and Stage 1 Pressure Injuries to Right Medial Great Toe ~1 x 1 x 0 cm & Left Heel ~2 x 4 x 0 cm. On 10/27/2021 the administrator told IB that:” Around early August of 2021 R1 suffered a stroke. Unfortunately, R1 wasn't the same after this. R1 became harder to care for as R1 became more confused, physically frailer, and it became more difficult for R1 to sit or stand.“ Caregiver S1 told IB that “On 08/27/2021, R1 woke up screaming in pain when we tried to tum R1 from side to side to change R1’s diaper. After that it just got so bad that I didn't want to move or transfer R1 because R1 was in so much pain. R1 screamed when we moved them to wheelchair, turned them, any transfer that we did R1 screamed. On 09/06/2021 I noticed the pressure sores on R1’s body. I reported this to home health on 09/08/21 and they said R1 needs to go to the hospital.” Caregiver S2 stated “When R1 screamed, I didn't want to move R1 anymore, so R1 stayed in bed. On 09/06/2021 I noticed R1 developed the sores on their body. I think R1 got the sores because when we moved R1, R1 screamed, and we didn't want to cause R1 more pain, so we left R1.” Regarding the allegation “Resident developed multiple pressure injuries while in care.” Based on interviews which were conducted and the records that were reviewed by IB, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20210921093903
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: AMERICARE ASSISTED LIVING OF ROLLING HILLS
FACILITY NUMBER: 197607689
VISIT DATE: 10/20/2022
NARRATIVE
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Regarding the allegation: “Resident sustained a fracture while in care.” Record reviews conducted by IB on 10/27/2021 indicate that during hospital admission on 09/17/2021 x-ray results showed that R1 had a fracture on the right hip femoral neck. On 10/27/2021 the administrator stated:” Around early August of 2021 R1 suffered a stroke. Unfortunately, R1 wasn't the same after this. R1 became harder to care for as R1 became more confused, physically frailer, and it became more difficult for R1 to sit or stand.” Caregiver S1 stated: “It was actually on 08/26/2021 that R1 fell. R1 didn't verbalize any pain. R1 didn't have any head injuries that I could see. I did a body check and saw no cuts or bruises on their body. There was nothing that I saw that was alarming to me. I gave R1 some Tylenol and I called their family to tell them what happened. I thought R1 needed an x-ray after the next day R1 screamed. On 08/27/22021 we arranged a portable x-ray, but R1’s insurance declined it.” Caregiver S2 stated “I didn't see R1 fall because I was assisting R2 in the bathroom. S1 was in the other bathroom helping out another client.” On 11/01/2021 witness W1 stated: “This fracture occurred on 08/26/2021 and she wasn't taken here until three weeks later. The facility still should have stepped in and forced their hands because family didn't seem to know better.” Regarding the allegation: “Resident sustained a fracture while in care.” Based on interviews which were conducted and the records that were reviewed by IB, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.


At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

At this time a $500 Civil Penalty is assessed.

An exit interview was conducted, plans of corrections were developed. A copy of this report and appeals rights were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210921093903
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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMERICARE ASSISTED LIVING OF ROLLING HILLS
FACILITY NUMBER: 197607689
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2022
Section Cited
CCR
87411(d)(5)
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Personnel Requirements – General. All personnel shall be given on the job training or have related experience in the job assigned to them....This requirement was not met as evidenced by:
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Licensee shall ensure all staff receive training on Emergency Procedures/ Care for Elderly Residents and submit sign in sheet, training materials and instructor information to Licensing by the POC due date.

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Based on record reviews and interviews conducted by Investigator (IB) Dennis Seng the licensee failed to ensure that staff had the knowledge necessary in order to recognize early signs of illness and the need for professional help. Staff S1 and S2 recognized R1 having pressure sores but failed to seek professional help even after being told to by R1’s home health agency which poses an immediate health, safety or personal rights 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20210921093903
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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: AMERICARE ASSISTED LIVING OF ROLLING HILLS
FACILITY NUMBER: 197607689
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2022
Section Cited
CCR
87615(a)(1)
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87615(a)(1) Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to,..... This requirement was not met as evidenced by:

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Licensee shall review Title 22 regulations regarding Prohibited Health Conditions and submit a statement confirming review of the regulations and acknowledging understanding.

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Based on record reviews and interviews conducted by Investigator (IB) Dennis Cheng the licensee failed to ensure that residents with stage 3 pressure injuries are not retained at the facility, R1 developed Stage III pressure injuries on left sacrum and right buttocks while in care which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
10/27/2022
Section Cited
CCR
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Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. ....This requirement was not met as evidenced by:

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Licensee shall ensure all staff receive training on observation of the residents and submit sign-in sheet, training materials and instructor information to Licensing by POC due date.
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Based on record reviews and interviews conducted by Investigator (IB) Dennis Cheng the licensee failed to ensure that observation of unmet needs are brought to the attention of the resident's physician, staff failed bring R1’s complaints of pain and pressure sores to attention of R1’s physician which poses an immediate health, safety or personal rights 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5