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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608379
Report Date: 05/12/2022
Date Signed: 10/30/2023 01:27:24 PM

Unsubstantiated


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
10/11/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20211011095607
FACILITY NAME:AVENIDA VILLA, INC.FACILITY NUMBER:
197608379
ADMINISTRATOR:PHILLIP ROMEROFACILITY TYPE:
740
ADDRESS:1803 AVENIDA FELICIANOTELEPHONE:
(310) 930-6455
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 5DATE:
05/12/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:LICENSEE ZENAIDA BUNAGTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff are not following Physician's orders
Staff are not changing resident timely
Staff are double diapering residents
Resident developed pressure injuries while in care
Resident is not being turned every 2 hours
Resident is not being cleaned properly
INVESTIGATION FINDINGS:
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This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 05/12/2022
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility on 05/12/2022 and was greeted by Administrator Phillip Romero (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10-day visit on 10/12/2021. LPA Calderon initiated an investigation for the above-mentioned allegations and conducted in-person interview with (A1).

Investigation consisted of: LPA Calderon interviewed A1, S1-S3, and W1. These interviews were conducted on 10/12/2021 and 09/11/2023. LPA was unable to interview R1-R4 due to impairments. LPA Calderon obtain and reviewed the following: staff and residents’ roster, Incident reports (dated 10/08/2021) for current complaint, physician’s report (dated 09/30/2021), appraisal/needs and service plan (dated 10/01/2021). On 09/18/2023, LPA Calderon requested repositioning Logs (dated 10/19/2021 to 01/22/2022), May 2022 Medication Administration Records (MAR) for R1. LPA Calderon obtained and reviewed in-service staff training for pressure injury wound care (dated 09/06/2021) and incontinent care (dated 09/13/2021). LPA Calderon obtained and reviewed physician orders (dated 10/11/2021), and Cleveland Clinic caring for pressure injures training (dated 09/06/2021). On 09/18/2023, LPA Calderon reviewed and obtained hygiene assistance staffing logs (dated 10/19/2021 to 01/22/2022) and Sponge bath logs (dated 10/19/2021 to 01/22/2022) for R1.

The investigation revealed the following:



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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 4
Control Number 11-AS-20211011095607
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: AVENIDA VILLA, INC.
FACILITY NUMBER: 197608379
VISIT DATE: 05/12/2022
NARRATIVE
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Regarding Allegation #1: Staff are not following Physicians orders. This complaint alleged that the administrator informed staff not to follow the physicians’ orders of washing the buttocks area with soap and water for R1. On 10/12/2021 LPA Calderon obtained and reviewed the physicians order dated 10/11/2021 for R1. The order states that the back bilateral buttocks and groin will be cleanse with soap and water. The order states the groin will be pat dried gently, and nystatin powder as well as triamcinolone cream 0.1% applied twice a day. The treated area would then be exposed to the open air. LPA Calderon conducted an interview with A1. A1 expressed that all staff follow the physician orders (dated 10/11/2021) for R1. LPA Calderon interviewed S1-S3 and 3 out of 3 staff expressed that they follow the physicians order and were trained to provide R1 with physician ordered care. LPA Calderon obtained and reviewed care plan records (dated 10/19/2021-01/22/2022) and found staff assisted R1 with incontinence services, repositioning, and applying ordered powder as well as medicated creams daily. On 05/12/2022 LPA Calderon reviewed Medication Administration Record for (May 2021) and found nystatin powder and triamcinolone 0.1% cream were administered per the physician’s order. 10/12/2021 LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments. LPA conducted an interview with W1 who visited R1 three times per week and expressed observing R1 being washed with soap and water when visiting. W1 was unable to confirm an absence of care was occurring when W1 was not present.

Regarding Allegation #2: Staff are not changing R1 diaper timely.

This complaint alleged staff are not changing R1 diaper every 2 hours.

On 10/12/2021 LPA Calderon obtained and reviewed the physicians order dated 10/11/2021 for R1. The order stated that R1 diaper should be changed every 2 hours or when needed. LPA Calderon interviewed A1. A1 state all staff follow the physician orders (dated 10/11/2021) for R1. LPA Calderon interviewed S1-S3 and 3 out of 3 staff expressed that S1-S3 were trained to change R1 diaper every 2 hours or when needed. 3 out of 3 staff expressed that S1-S3 were given incontinent training from A1 (dated 09/13/2021). 3 out of 3 staff expressed that staff keeps incontinent log records on changing resident every 2 hours (dated 10/19/2021 to 01/22/2022). LPA Calderon obtained and reviewed in service training for incontinent care and noted incontinent services provided every 2 hours to R1 (dated 10/19/2021 to 01/22/2022). LPA Calderon conducted an interview with W1 who visited R1 three times per week and states observing R1 incontinent services provided by staff every time W1 visited R1. W1 was unable to confirm an absence of care was occurring when W1 was not present. LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 11-AS-20211011095607
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: AVENIDA VILLA, INC.
FACILITY NUMBER: 197608379
VISIT DATE: 05/12/2022
NARRATIVE
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Regarding Allegation #3: Staff are double diapering residents.

This complaint alleged that staff are putting 2 diapers on R1. On 10/12/2021 LPA Calderon obtained and reviewed the physician order dated 09/30/2021 for R1. The order states that R1 has incontinent issues and needs to have incontinent services every 2 hours. LPA Calderon conducted an interview with A1. A1 expressed that S1-S3 were given incontinent care training on how to put a diaper on R1 (dated 09/13/2021). LPA Calderon interviewed S1-S3 and 3 out 3 staff expressed that A1 gave training to staff regarding diaper changing dated 09/13/2021. 3 out of 3 staff expressed that they would never put 2 diapers on R1 for any reason. LPA Calderon conducted an interview with W1 who visited R1 three times per week and expressed observing R1 diaper changed every 2 hours. W1 was unable to confirm an absence of care was occurring when W1 was not present. LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments.

Regarding Allegation #4: Resident developed pressure injuries while in care.

This complaint alleged that R1 developed stage 2 pressure injuries to buttocks and back area while in care. On 09/18/2023 LPA Calderon obtained and reviewed the physician orders dated 09/30/2021. The order stated that staff reposition R1 every two hours. LPA Calderon conducted an interview with A1. A1 expressed that staff follow the physician order (dated 09/30/2021) for R1. LPA Calderon interviewed S1-S3 and 3 out of 3 staff expressed that all staff are given training in pressure injuries/bedsores from A1 (dated 09/06/2021). 3 out of 3 staff expressed that staff reposition R1 every 2 hours per the training given to them from A1 and the Cleveland Clinic training guide (dated 09/06/2021). LPA Calderon obtained and reviewed needs and service plan (dated 10/01/2021), reposition log notes (dated 10/19/2021 to 01/22/2022) and found staff assisted R1 reposition every 2 hours. LPA Calderon conducted an interview W1 who visited R1 three times per week and expressed that R1 did not have any sores on R1 buttocks area when R1 moved into the facility. W1 expressed that W1 does not believe that staff reposition R1 every 2 hours as directed from doctors’ orders but W1 has no proof. W1 expressed to have observed staff reposition R1 every 2 hours when visiting. W1 was unable to confirm an absence of care was occurring when W1 was not present. LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20211011095607
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: AVENIDA VILLA, INC.
FACILITY NUMBER: 197608379
VISIT DATE: 05/12/2022
NARRATIVE
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Regarding Allegation #5: Resident is not being turned every 2 hours. This complaint alleged that R1 is not being repositioned every 2 hours per physician order. On 10/12/2021 LPA Calderon obtained and reviewed the physician order dated 09/30/2021. The order stated that staff reposition R1 every two hours. LPA conducted an interview with A1. A1 expressed that all staff follow the physician orders (date 09/30/2021) for R1. LPA Calderon interviewed S1-S3 and 3 out of 3 staff expressed that they follow the physician order and were trained to provide R1 with physician ordered care. 3 out of 3 staff state that they reposition R1 every two hours. On 09/18/2023 LPA Calderon obtained and reviewed reposition and incontinent care log notes (dated 10/19/2021 to 01/22/2022) and found staff assisted R1 with repositioning services. LPA Calderon conducted an interview with W1 who visited R1 three times per week and expressed observing R1 being repositioned every 2 hours by staff. W1 was unable to confirm an absence of care was occurring when W1 was not present. LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments.Regarding Allegation #6: Resident is not being cleaned properly. This complaint alleged that staff are not giving R1 a bath while in care. On 10/12/2021 LPA Calderon obtained and reviewed the physicians order dated 10/11/2021 for R1. The order said that the back bilateral buttocks and groin will be cleanse with soap and water. The order states the groin will be pat dried gently, and nystatin powder as well as triamcinolone cream 0.1% applied twice a day. The treated area would then be exposed to the open air. LPA Calderon conducted an interview with A1. A1 expressed that all staff follow the physician orders (dated 10/11/2021) for R1. LPA Calderon conducted an interview with A1. A1 expressed that all staff follow the physician orders (dated 10/11/2021) for R1. LPA Calderon interviewed S1-S3 and 3 out of 3 staff expressed that they follow the physician order and were trained to provide R1 with physician ordered care. LPA Calderon obtained and reviewed bath care log records (dated 10/19/2021-01/22/2022) and found staff assisted R1 with sponge bath services. LPA conducted an interview with W1 who visited R1 three times per week and expressed observing R1 being washed with soap and water when visiting. W1 was unable to state that staff did not provide a sponge bath was occurring when W1 was not present. W1 was unable to confirm an absence of care was occurring when W1 was not present. LPA Calderon attempted to interview R1-R4. 4 out of 4 residents were unable to communicate due to impairments. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of Staff are not following Physician's orders, Staff are not changing resident timelyStaff are double diapering residents, Resident developed pressure injuries while in care, Resident is not being turned every 2 hours, Resident is not being cleaned properly is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to the Administrator A1

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4