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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602263
Report Date: 11/09/2021
Date Signed: 11/09/2021 12:34:22 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2020 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200213103247
FACILITY NAME:NP CARE HOMEFACILITY NUMBER:
198602263
ADMINISTRATOR:TATUM, RONICFACILITY TYPE:
740
ADDRESS:3767 VIRGINIA ROADTELEPHONE:
(323) 205-5145
CITY:LOS ANGELESSTATE: CAZIP CODE:
90016
CAPACITY:6CENSUS: 6DATE:
11/09/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Krystal AdamsTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for resident who sustained a fracture to hip requiring surgery.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent visit to deliver complaint investigation findings. LPA met with Licensee Krystal Adams and explained the purpose of the visit.

Investigation consisted of the following: During the initial visit conducted on 2/18/20, LPA Gonzalez requested a copy of Staff and Resident rosters, reviewed Resident 1-3 (R1-3) facility files, and collected copies of various documents from resident files. LPA Gonzalez and Licensee Krystal Adams conducted a tour of the entire facility inside and out which included a Health & Safety check and observation of residents. LPA did not observe any signs of neglect, abuse or other immediate Health & Safety concerns at the time of the visit.

The investigation for this complaint was conducted by Investigator Lorraine Patterson.


(See LIC 9099C for continuation of report)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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 28-AS-20200213103247
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: NP CARE HOME
FACILITY NUMBER: 198602263
VISIT DATE: 11/09/2021
NARRATIVE
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During the course of this investigation, Investigator Patterson conducted interviews with R1's FM and Licensee Krystal Adams.

The investigation revealed the following: Regarding allegation of Staff did not seek timely medical attention for resident who sustained a fracture to hip requiring surgery. Investigator Patterson interviewed R1's FM who stated that on 1/15/20 they received a call from the facility licensee/ administrator, Krystal Adams, who reported to them that R1 had sustained an unwitnessed fall on 1/14/20 that went unreported by S1-2. R1's FM reported to Investigator Patterson that they were also informed that S1-2 assisted R1 back into bed after the unwitnessed fall. R1's FM stated that R1 did not receive timely medical care after the fall and was not assessed until 1/16/20 at which time GL Hospice came to the facility to take a portable x-ray of R1. X-Rays showed that R1 sustained a hip fracture and required surgery. R1 was taken off of hospice care on 1/17/20 due to the need for surgery and was transported via private ambulance, which was paid by the facility, to UCLA Santa Monica and had hip surgery on 1/18/20. R1 did not return to the facility after their discharge from the hospital and was placed in a Skilled Nursing Facility.

Investigator Patterson also interviewed Licensee/ Administrator Krystal Adams, who confirmed that R1 fell on 1/14/20 and that S1 and S2 both failed to report the fall to licensee/ administrator. Licensee Adams stated that she found out about the fall/ injury until nearly 24 hours after the incident when another facility staff (S3) called her to notify her and asked her to come to the facility to assess R1. Mrs. Adams stated that she arrived at the facility late in day on 1/15/20 and she assessed R1 and being a medical professional (Nurse Practitioner) she noticed immediately that one of R1's legs looked shorter than the other and required medical attention, at which time she contacted R1's family members and GL Hospice. Licensee also stated that R1 did not receive medical attention until 1/16/20 when a Registered Nurse from GL Hospice visited R1 and took X-Rays which confirmed that R1 sustained a hip fracture and required surgery. Licensee stated that she informed R1's family about R1's need for surgery at which time the family struggled to decide on whether to call 911 or to use private transportation due to hospital preferences. Licensee stated that R1 was transported to UCLA Santa Monica via private ambulance paid for by the facility. R1 was admitted to the hospital on 1/17/20 and had hip surgery on 1/18/20. Licensee stated that R1 did not return to the facility.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 28-AS-20200213103247
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: NP CARE HOME
FACILITY NUMBER: 198602263
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2021
Section Cited
CCR
87468.2(a)(8)
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Additional Personal Rights of Residents in Privately Operated Facilities To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
This requirement was not met as evidenced by:
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Licensee is to retrain staff in residents needs and staff responsibilities and provide copy of training to LPA by Plan of Correction (POC) date.
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R1 sustained a hip fracture on 1/14/20 that subsequently required surgery and facility staff did not report injuries to facility administrator/licensee until nearly 24 hours later. This poses an immediate hazard to residents in care.
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**Immediate Civil Penalties will be assessed in the amount of $500.00.**
Type A
11/10/2021
Section Cited
CCR
87466
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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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Licensee shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87464(d). Written POC must be submitted to CCL by the POC due date.
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This requirement was not met as evidenced by: R1 sustained a hip fracture on 1/14/20 that subsequently required surgery and facility staff did not report injuries to facility administrator/ licensee until nearly 24 hours later. This poses an immediate hazard 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: Rebecca Orendain
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20200213103247
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: NP CARE HOME
FACILITY NUMBER: 198602263
VISIT DATE: 11/09/2021
NARRATIVE
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Immediate Civil Penalties will be issued today, in the amount of $500.00 due to Staff did not seek timely medical attention for resident who sustained a fracture to hip requiring surgery.

At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1548(f)(1)(B)(i) and may be assessed at a later date.

Exit interview held. A copy of the LIC9099, LIC9099C, LIC9099D and LIC421M (Civil Penalty Assessment), and Appeal Rights were provided to Licensee Krystal Adams.

SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4