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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608232
Report Date: 12/16/2021
Date Signed: 12/16/2021 04:50:42 PM

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
11/13/2019 and conducted by Evaluator Ulysses Coronel
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20191113101336
FACILITY NAME:SUMMER HOUSE AT LADERA HEIGHTSFACILITY NUMBER:
197608232
ADMINISTRATOR:SHERRYL RAFOLSFACILITY TYPE:
740
ADDRESS:6108 DAMASK AVENUETELEPHONE:
(323) 792-4105
CITY:LOS ANGELESSTATE: CAZIP CODE:
90056
CAPACITY:4CENSUS: 4DATE:
12/16/2021
UNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Sherryl Rafols and Mark LooTIME COMPLETED:
11:47 AM
ALLEGATION(S):
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Severe neglect resulting in resident developing a pressure injury.
Facility failed to address resident's change in medical condition .
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ulysses Coronel made an unannounced visit to the facility, LPA met with caregiver Crisostomo Gaytos and spoke to Administrators Sherryl Rafols and Mark Loo via telephone. The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

The insvestigation consisted of the following: Licensing Program Analyst (LPA Jennifer Jones) conducted the Initial 10-Day visit on 11/14/19. During the visit, LPA Jones met with Staff #1 (S1: Crisostono Gaytos) and Staff #2 (S2: Marilyn Nery), toured the facility, reviewed Residents (1-5) files, and obtained copies of Resident #1's files (Physician’s Report, Admission Agreement, Emergency Contact Info, and Home Health Agency notes) including facility staff training records. A separate investigation was conducted by the Department of Social Services Investigator (Laura Garcia) which included reviewing medical records and home health agency notes (dated 08/29/19 – 11/06/19); interviews with facility staff, residents’ relatives, home health staff, and medical staff.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
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 4
Control Number 11-AS-20191113101336
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: SUMMER HOUSE AT LADERA HEIGHTS
FACILITY NUMBER: 197608232
VISIT DATE: 12/16/2021
NARRATIVE
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Regarding Allegation #1: this investigation revealed that upon admission to the facility on 08/25/19, the physician’s report (dated 08/01/19) documented that Resident #1 (referred to as R1) had a history of skin condition/breakdown. Medical records (dated 08/26/19) noted a physical examination was performed on Resident #1 for pressure injuries present during hospital admission: right toe – Stage 2; Right heel – Stage 3 without surrounding erythema or purulence; severe Sepsis with acute organ dysfunction, non-traumatic acute kidney injury, BPH with urinary retention, Dementia, severe protein calorie malnutrition, venous statis edema with ulcer. Home health agency records (dated 08/26/19) documented that Resident #1 was referred to ComCare Home Health (an affiliate of Kaiser Permanente Medical Group) and was first seen by one of the on-site home health agency nurses on 08/29/19 for start of care. Home Health RN noted multiple wound locations: Unstageable pressure injuries on the left and right buttock/ open-skin injury on right toe, and open Stage 2 pressure injury on right heel. All wounds were reported to physician and coordinated to facility staff. ComCare Home Health Skilled Nurse (Florence Atena) instructed PCG’s in pressure management and prevention; of which, facility staff verbalized understanding. Medical records (dated 09/28/19) revealed that Resident #1 was hospitalized due to severe sepsis and was discharged back to the facility on 10/03/19. Resident #1 had wounds on: left heel – unstageable pressure injury; right heel – open Stage 2 pressure injury, measuring 3x3x0cm; right great toe – open skin injury, measuring 1x0.5x0cm; left buttock – unstageable . ComCare Home Health received the order (dated 10/04/19) to resume home health care to Resident #1. Staff #1 told ComCare Home Health Skilled Nurse, Florence Atena (on 10/11/19) that he had performed wound care on Resident #1’s sacrococcyx and did not allow Skilled Nurse Atena to turn Resident #1 (again) to check the wound. Skilled Nurse Atena documented and reported Resident #1’s health and behavioral condition. Based on Skilled Nurse Atena’s observations, it was believed that Resident #1 required a higher level of care. Skilled Nurse Atena continued daily wound care visits for Resident #1 and foley catheter change on 10/16/19. On 10/23/19, upon re-cert visit, Home Health RN, noted an unstageable pressure ulcer on Resident #1’s left hip and reported to medical doctor about the new wounds and recommended wound care treatment. On 11/06/19, Resident #1 was hospitalized due to a septic shock, dehydration, and pressure injuries. Resident #1 expired on 12/04/19. Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation NEGLECT/LACK OF SUPERVISION: Severe neglect resulting in resident developing a pressure injury is found to be SUBSTANTIATED.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 11-AS-20191113101336
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: SUMMER HOUSE AT LADERA HEIGHTS
FACILITY NUMBER: 197608232
VISIT DATE: 12/16/2021
NARRATIVE
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Regarding Allegation #2: this investigation revealed that on 10/23/19, it was determined that Resident (#1) (referred to as R1) was diagnosed with the following pressure injuries: Wound 1 – right heel (measured 6.7 x 6.5 cm); Wound 2 – left heel (measured 3.5 x 3.2 cm); Wound 3 – left hip (measured 10.4 x 6.7 cm); Wound 4 – right hallux, no odor, no drainage, wound bed appearance necrotic; Wound 5 – bilateral buttocks with moderate serosanguineous drainage, yellow wound bed appearance. ComCare Home Health instructions to facility staff were to keep these areas dry and clean as well as keeping pressure off by elevating and rotating Resident #1 regularly. A review of Resident #1’s “Needs and Services Plan” (dated 08/25/19) did not document information about potential pressure injuries or change in condition prior to the Resident #1’s hospitalization on 09/28/19. Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation NEGLECT/LACK OF SUPERVISION: Facility failed to address resident's change in medical condition is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency observed and citation issued (ref. LIC 9099D) – civil penalty will be assessed.

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.”

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to Administrators Sherryl Rafols and Mark Loo.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20191113101336
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: SUMMER HOUSE AT LADERA HEIGHTS
FACILITY NUMBER: 197608232
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2021
Section Cited
CCR
87615(a)(1)
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Prohibited Health Conditions: Persons who require health services or have a health condition including; but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure sores (dermal ulcers). This requirement is not met as evidenced by:
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The administrator shall read Title 22, Section 87615(a)(1) "Prohibited Health Conditions" and send a written statement to CCLD by the POC date that she will ensure to stay in constant communication with the medical professional; and if the resident's medical condition elevates (meaning they require a higher level of care),
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Upon admission R1 Physician’s Report (8/1/19) documented that R1 had a history of skin breakdown, Stage 3 pressure injury on the right heel/arterial ulcer. On 11/6/19, R1 had 3 unstageable pressure injuries. Staff was aware of R1’s wound condition and retained R1 with a prohibited health condition. R1 expired on 12/04/19.
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Administrator will ensure the resident is relocated to a skilled-nursing facility or hospital; and, the relocation will take place immediately. This POC is due to CCLD/El Segundo ASC Office on 12/17/2021.
Type A
12/17/2021
Section Cited
CCR
87466
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87466 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. When changes such as ... physical health condition are observed
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The administrator shall read Title 22, Section 87466 “Observation of the Resident” and send a written statement to CCLD by the POC date that Administrator will observe any change of condition by a resident and conduct an assessment of the resident and inform the resident’s physician
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, the licensee shall ensure that such changes are documented and brought to the attention of the resident’s physician and the resident’s responsible party, if any. This requirement is not met as evidenced by: Facility staff admitted to having knowledge of Resident #1’s change of medical condition.
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and resident’s responsible person of an outcome. The plan is due to CCLD/El Segundo ASC Office by POC date of 12/17/2021.
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: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4