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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320059
Report Date: 03/11/2022
Date Signed: 03/11/2022 05:33:45 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
04/03/2020 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200403131604
FACILITY NAME:OCEAN BREEZE CARE HOME IIFACILITY NUMBER:
198320059
ADMINISTRATOR:MACELLUEN, GREGGFACILITY TYPE:
740
ADDRESS:26509 ROLLING VISTA DRTELEPHONE:
(310) 721-9667
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 4DATE:
03/11/2022
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Gregg MacElluen, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident sustained injuries while in care.
Resident sustained multiple falls while at the facility due to lack of supervision by staff.
Facility staff failed to meet the resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto made an unannounced visit to the facility and was greeted by Administrator Gregg MacElluen. The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

Licensing Program Manager (LPM) Janae Hammond initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Gregg MaCelluen, the facility administrator.

LPM Hammond conducted telephone interviews with the administrator and a video call - which consisted of a review of food supply, physical plant, medication area, and reviewed Resident #1's records (Emergency ID Sheet, Physician’s Report, Admission Agreement, Needs & Service Plan, Physician’s Orders (for postural supports), Staff Training Logs (for 6 months).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
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 8
Control Number 11-AS-20200403131604
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: OCEAN BREEZE CARE HOME II
FACILITY NUMBER: 198320059
VISIT DATE: 03/11/2022
NARRATIVE
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Regarding Allegation #1: this investigation revealed that Resident #1 was transported to Providence Little Company of Mary Medical Center on 03/23/20 with a right thumb fracture, blunt head trauma, chronic anti-coagulation, and dementia. Resident #1 also had a large amount of soft tissue swelling on the left side of her head, but scans showed no evidence of an acute skull fracture or brain bleed. The two caregivers S1- S2 that were present during the fall both presented contradictory statements and were inconsistent in their interviews. Staff #1 claimed she was in the hallway when Resident #1 fell. Staff #1 stated that Staff #2 pushed and guided Resident #1 through the bedroom door towards the restroom – which was approximately 15 feet away from Resident #1’s bedroom. Both caregivers entered the bathroom with Resident #1 when she slid out of her wheelchair and hit her head on the floor. Staff #1 was in the bathroom facing away from Resident #1 and Staff #2. Staff #1 stated that she did not see the fall; but, she heard a loud bang noise and believed it was due to Resident #1 hitting her head on the hard floor after the fall from her chair. Staff #2 claimed that Resident #1 had a bowel movement in bed and needed to be transported to the bathroom to be cleaned. Resident #1 was placed on a transport wheelchair then led to the bathroom with one caregiver in front and another behind Resident #1. Staff #2 claimed Staff #2 initially stated they were right next to the bathroom door when Resident #1 fell very quickly from her transport wheelchair. Resident #1 slid forward off the transport wheelchair and bumped her head on the bathroom door jamb. Upon a follow-up interview with Staff #2 , she stated that she had observed Resident #1 hit her head on the hallway floor. After the fall, Staff #2 stated that Resident #1 sat on the hallway floor in a daze. Staff #2 noticed a bump on Resident #1’s head immediately. Staff #2 stated that she put ice on Resident #1’s head injury and called 911 immediately. Staff #2’s narrative did not coincide with the narrative given by Asst. Administrator. Staff #2 stated she called 911 immediately, while Asst. Administrator claimed that she put ice on Resident #1’s head injury and called 911 immediately. Review of Resident #1 records revealed Resident was a fall risk. Staff #2’s inconsistent interview responses and both witness’ contradictory statements placed doubt on how well Resident #1 was being supervised before the fall and how well Resident #1 was being taken care of while being transferred to the bathroom.

Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE: Resident sustained injuries while in care is found to be SUBSTANTIATED.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20200403131604
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: OCEAN BREEZE CARE HOME II
FACILITY NUMBER: 198320059
VISIT DATE: 03/11/2022
NARRATIVE
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Regarding Allegation #2: When Resident #1 arrived to the facility on 02/21/20, the facility provided a queen-size bed; and, staff were told that this was dangerous because Resident #1 was a fall risk. The very first day 02/21/2022, Resident #1 was lying in bed and during the night fell onto the ground. Administrator stated that Resident #1 had rolled off the bed onto some pillows that were placed on the ground near the bed. Although, Resident #1 may have landed onto the pillows, the resident sustained a bump on her head. Facility did not agree initially to a hospital bed for Resident #1, but eventually provided a hospital bed (w/ half rails) that arrived one (1) week later. Witness #3 mentioned that Resident #1 fell multiple times during the day; but, could not recall exactly how many times or dates that Resident #1 had fallen at the facility. Witness #3 claimed that while facility staff transported residents to the restroom and out of their wheelchair, observed that facility staff were often extremely forceful and rough. Witness #3 observed no uniformity or standard operating procedure from facility staff when residents were being transported. Although, Asst. Administrator indicated that facility was unaware of Resident #1 being a fall risk. A review of Resident #1’s “Physician’s Report” (dated 11/15/19) under “Capacity for Self Care” documents Resident #1 cannot ambulate without assistance. “Resident Appraisal” (dated 02/19/20) under “Functional Capabilities” documents Resident #1 needs assistance with walker and wheelchair. A physician’s order (dated 03/02/20) documents a “Semi-electric hospital bed with ½ rails” was still current and prescribed by her physician.

Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE: Resident sustained multiple falls while at the facility due to lack of care/supervision by staff is found to be SUBSTANTIATED.

Regarding Allegation #4: this investigation revealed that Witness #2 noticed during visits to the facility, staff provided poor care and were poorly trained. Resident #1 developed a diaper rash while living at the facility; of which, Resident #1 never had skin issues before she arrived at the facility and due to the infrequent diaper changes, it led to her diaper rash. Witness #2 claimed hospice supplies were delivered and signed for, but were not able to be located - including a wheelchair that was provided for Resident #1 was nowhere to be found at the facility. Administrator and Asst. Administrator had no explanation for the missing supplies and equipment (wheelchair) or the hospital bed (w/rails) that was delivered a week late.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20200403131604
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: OCEAN BREEZE CARE HOME II
FACILITY NUMBER: 198320059
VISIT DATE: 03/11/2022
NARRATIVE
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Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE: Facility staff failed to meet the resident’s needs is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency was observed and a citation issued (ref. 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.”

Civil Penalties Assessed.

An exit interview was conducted and a copy of the Complaint Report and Appeal Rights were provided to Administrator

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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
04/03/2020 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200403131604

FACILITY NAME:OCEAN BREEZE CARE HOME IIFACILITY NUMBER:
198320059
ADMINISTRATOR:MACELLUEN, GREGGFACILITY TYPE:
740
ADDRESS:26509 ROLLING VISTA DRTELEPHONE:
(310) 721-9667
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 4DATE:
03/11/2022
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Gregg MacElluen, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff restrained resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto made an unannounced visit to the facility and was greeted by Administrator Gregg MacElluen. The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

Licensing Program Manager (LPM) Janae Hammond initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Gregg Mac Elluen, the facility administrator.

LPM Hammond conducted telephone interviews with the administrator and a video call - which consisted of a review of food supply, physical plant, medication area, and reviewed Resident #1's records (Emergency ID Sheet, Physician’s Report, Admission Agreement, Needs & Service Plan, Physician’s Orders (for postural supports), Staff Training Logs (for 6 months).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20200403131604
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: OCEAN BREEZE CARE HOME II
FACILITY NUMBER: 198320059
VISIT DATE: 03/11/2022
NARRATIVE
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Regarding Allegation #3: this investigation revealed that the medical professionals did not suspect abuse and attributed the physical injuries from the witnessed fall that Resident #1 sustained. All facility caregivers and administrators denied Resident #1 was ever physically abused or physically restrained while in care at the facility. Majority interviews conducted expressed how they enjoyed the care and services they received at the facility; and, they did not observe physical abuse or residents being restrained. Witnesses interviewed did not suspect physical abuse nor residents being restrained during their visits to the facility.

Based on the evidence gathered and interviews conducted and records reviewed, the allegation may have happened or is valid; however, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PHYSICAL ABUSE: Facility staff restrained resident is found to be UNSUBSTANTIATED.

An exit interview was conducted and a copy of the Complaint Report was provided to Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20200403131604
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: OCEAN BREEZE CARE HOME II
FACILITY NUMBER: 198320059
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/28/2022
Section Cited
CCR
87705(c)(4)
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87705(c)(4): Care of Persons with Dementia. (c) Licensee who accept and retain residents with dementia shall be responsible for ensure the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety, and health care needs as identified in his/her current appraisal. This requirement is not met as evidence by:
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Administrator shall provide training to resident in care for persons with Dementia. The Administrator shall provide a copy of the training materials and sign-in sheet and submit to CCL by POC due date. A $500 immediate civil penalty was assessed.
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Based on interviews conducted and records reviewed the Licensee failed to ensure Residents #1 needs were met resulting in the resident sustaining serious bodily injuries. This poses a health and safety risk to residents in care.
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Request Denied
Type B
03/28/2022
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..........
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Administrator shall provide staff with training on observation of the residents. Administrator will provide copies of training materials and sign in sheet to CCL by POC due date.
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Based on interviews and records reviewed the licensee failed to ensure after repeated falls R1 was reassessed. This poses an health & safety risk to resident 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: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20200403131604
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: OCEAN BREEZE CARE HOME II
FACILITY NUMBER: 198320059
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/28/2022
Section Cited
CCR
87468.1(a)(1)(2)
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87468.1(a)(1)(2): Personal Rights of Residents in all Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: .......
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Administrator shall ensure residents belongings are properly stored and secured. Administrator shall train stall in residents Personal Rights. Administrator shall provide training materials and sign in sheet to CCL by POC due date.

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Based on interviews and records review the licensee failed to ensure R1 belongings were properly safeguarded. This poses a personal rights risk to residents 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: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8