198602898-3-10-2022-11-AS-JHAD-CCGUH4-20220313153517

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602898
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:57:26 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
01/14/2022 and conducted by Evaluator Ulysses Coronel

COMPLAINT CONTROL NUMBER: 11-AS-20220114144027

FACILITY NAME:	BELLA MANOR II		FACILITY NUMBER:	198602898
ADMINISTRATOR:	ATENCIO, CHRISTINA		FACILITY TYPE:	740
ADDRESS:	7800 E. TULA STREET		TELEPHONE:	(310) 953-5518
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	6	CENSUS: 5	DATE:	03/10/2022
		UNANNOUNCED	TIME BEGAN:	12:59 PM
MET WITH:	Christina Atencio		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Resident received injuries while in care.
Staff are not changing residents socks.
Staff are not ensuring resident drinks enough water.
Resident devloped a pressure injury while in care.

INVESTIGATION FINDINGS:

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On 03/10/2022 Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegations listed above. LPA met with Christina Atencio the facility administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 01/18/2022 LPA Coronel interviewed the administrator ,2 staff, 2 residents and requested and reviewed facility and resident records. On 03/07/2022 LPA conducted record reviews. On 03/10/2022 LPA conducted a tour of the facility, record reviews of resident’s records and interviewed the administrator ,2 staff, 4 residents and 2 witnesses. 1 out of 5 residents R5 is not at the facility.

The investigation revealed the following: Regarding the allegation, “Resident received injuries while in care.” On 03/07/2022 R1’s Home Health Record reviews indicate that R1 slid down wheelchair, with worsening of skin tear. Patient unknowingly scratches wound. On 03/10/2022 record reviews indicate that R1 takes a blood thinner Eliquis.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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 3

Control Number 11-AS-20220114144027

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: BELLA MANOR II	FACILITY NUMBER: 198602898
	VISIT DATE: 03/10/2022

NARRATIVE

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On 03/10/2022 the administrator and 2 staff denied the allegation, caregiver S1 stated. “Most of R1’s wound are from scratching Themselves. 3 out of 4 residents denied the complaint, R2 stated “I have not heard of anyone getting injured here.” R1 was not available for interview. Witness W1 stated. “R1 is very fragile, their skin breaks down easily due to taking Eliquis. Regarding the allegation, “Resident received injuries while in care.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation, “Staff are not changing residents’ socks.” On 03/10/2022 LPA observed that R1 was wearing a clean pair of socks and had at least 6 pairs of socks in their drawer. On 03/10/2022 the administrator and 2 staff denied the allegation, staff S2 stated “We change residents including R1’s socks daily, R1 has mostly dark colored socks. 3 out of 4 residents denied the allegation, R4 stated “Someone is always here, they always change our clothes .” R1 was not available for interview. Witness W1 stated,” R1 always looked good, I visit always every day. I would know if there were any problem.” Regarding the allegation, “Staff are not changing residents’ socks.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation, “Staff are not ensuring resident drinks enough water.” On 03/10/2022 LPA observed that residents R2 and R4 had glasses of water by their bedside. During record reviews LPA observed that per doctors order R2 is on a Restricted Fluid intake of 1000 ml per day. On 03/10/2022 the administrator and staff denied the allegation, staff S1 stated that “I make sure that each resident has a water bottle by their side.” 3 out 4 residents denied the allegation, R2 stated “I don’t have any complaints about water, they fill up my cup when it gets empty.” R1 was not available for interview. Witness W2 stated, “That is not a problem, R2 cannot drink too much water and is only allowed to take 1000 ml of fluids daily, R2 has had this condition since 2018.” Regarding the allegation, “Staff are not ensuring resident drinks enough water.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation, “Resident developed a pressure injury while in care.” On 03/07/2022 R2’s Home Health records indicate that on 01/17/2022 – “Skilled Nurse assessed patient (R2) with new right buttocks boil that is firm and red.”

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220114144027

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: BELLA MANOR II	FACILITY NUMBER: 198602898
	VISIT DATE: 03/10/2022

NARRATIVE

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On 03/10/2022 the administrator and 2 staff denied the allegation, the administrator stated, “R2 never had a pressure injury, R2 had a boil and it’s now healed. On 03/10/2022 3 out of 4 residents denied the allegation, R2 stated “No I do not have any, a nurse comes here and looks after me, his name is Steven.” Witness W2 stated, “I visit often R2 never had pressure injuries, there may be redness here and there but they would tell me about them and they get better eventually.” Regarding the allegation, “Resident developed a pressure injury while in care.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted. A copy of this report was provided to Christina Atencio the facility administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

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