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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603601
Report Date: 11/05/2024
Date Signed: 11/05/2024 02:51:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2024 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240213110519
FACILITY NAME:GRANT SERENITY OF DEL MAR INC.FACILITY NUMBER:
198603601
ADMINISTRATOR:ADJIAN, MARTINFACILITY TYPE:
740
ADDRESS:3049 E. DEL MAR BLVDTELEPHONE:
(818) 425-6797
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 6DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Claudia Almeida - StaffTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Staff did not reposition resident resulting in resident sustaining a stage 4 pressure injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Claudia Almeida and explained the reason for the visit.

The investigation consisted of the following: On 2/14/24 LPA Flores conducted a health and safety check visit at the facility and requested pertinent documents for resident #1(R1). On 2/26/24 LPA subpoena medical records for R1 from hospice services. On 7/29/24 LPA submitted a clinical consult. On 8/14/24 a follow up clinical consult was submitted to the department regarding the above allegation. On 8/30/24 LPA received clinical consult report. On 11/5/24 LPA Flores conducted a subsequent visit and delivered findings.

The investigation revealed the following: Regarding allegation: Staff did not reposition resident resulting in resident sustaining a stage 4 pressure injury. It is alleged within six days of R1’s arrival to the facility a large and serious pressure ulcer developed. (CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
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 5
Control Number 28-AS-20240213110519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GRANT SERENITY OF DEL MAR INC.
FACILITY NUMBER: 198603601
VISIT DATE: 11/05/2024
NARRATIVE
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On 3/22/23 R1 was admitted to the facility, on the same day R1 initiated hospice care services. The same day, upon admission hospice nurse noted R1 exhibit Deep Tissue Injuries (DTI) and moisture associate with skin damage (MASD). On 3/29/23 additional DTIs were noted by hospice nurse. On 4/5/23 additional DTIs were observed by hospice nurse and wound care specialist was contacted. On 4/5/23 wound care specialist visited R1 and noted stage 3 and stage 4 wounds. Interviews conducted with staff revealed staff became aware R1 developed wounds. Staff were familiar with and instructed by hospice nurse to reposition R1 at least every two hours. Interviews with R1’s family members revealed, they had noticed that at the beginning it was difficult for the facility to provide care due to R1’s declined condition. However, family members felt that within a week facility staff was providing proper care and repositioning R1 as needed. Documents reviewed revealed R1 initiated hospice due to cognitive impairment, there are no other health conditions or health history noted. Hospice visits notes noted hospice nurse had provided training to facility staff and recommended R1 was reposition every two hours. Facility maintained a reposition log, per monthly reposition logs maintain between 3/29/23 to 4/5/23, R1 was reposition no more than between 1-3 times per day in a 24-hour period. Therefore, this allegation is substantiated.

Based on LPAs interviews which were conducted and document records review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

***An immediate Civil Penalty of $500.00 is being issued today, due to Resident #1 developing stage 3 and 4 wounds in a period of 7 days due to lack of repositioning as directed by hospice staff while in care. Refer to LIC 421IM***

The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect.

Exit interview was conducted with Claudia Almeida and a copy of this report, LIC 9099D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240213110519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRANT SERENITY OF DEL MAR INC.
FACILITY NUMBER: 198603601
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents...: (a)... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff... to meet their needs. This requirement is not met as evidence by:
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Administrator will provide staff with hospice, repositioning, wound prevention, observation, and care and submit a copy of training log with duration, topic, and sign-in log to the department by POC due date 11/6/24.
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Based on interviews and document review conducted licensee failed to prevent R1 developed stage 3 and 4 wounds within 7 days of admission which poses an immediate health, safety, or personal rights risk to the persons 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.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2024 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240213110519

FACILITY NAME:GRANT SERENITY OF DEL MAR INC.FACILITY NUMBER:
198603601
ADMINISTRATOR:ADJIAN, MARTINFACILITY TYPE:
740
ADDRESS:3049 E. DEL MAR BLVDTELEPHONE:
(818) 425-6797
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 6DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Gloria Almeida - StaffTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Questionable death.
Staff did not change resident's diaper in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Claudia Almeida and explained the reason for the visit.

The investigation consisted of the following: On 2/14/24 LPA Flores conducted a health and safety check visit at the facility and requested pertinent documents for resident #1(R1). On 2/26/24 LPA subpoena medical records for R1 from hospice services. On 7/29/24 LPA submitted a clinical consult. On 8/14/24 a follow up clinical consult was submitted to the department regarding the above allegation. On 8/30/24 LPA received clinical consult report. On 11/5/24 LPA Flores conducted a subsequent visit and delivered findings.

The investigation revealed the following: Regarding allegation: Questionable death. It is alleged facility’s negligence of care contributed to R1’s death on 6/28/23. On 3/22/23, R1 was admitted to the facility and initiated hospice care. (CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240213110519
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GRANT SERENITY OF DEL MAR INC.
FACILITY NUMBER: 198603601
VISIT DATE: 11/05/2024
NARRATIVE
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Hospice nurse noted R1 was observed with Deep Tissue Injuries and moisture associate by skin damage MASD by hospice nurse, upon initiating hospice on 3/22/23. Between 3/29/23 to 4/5/23 R1 developed stage 3 and stage 4 wounds which were noted by a wound specialist on 4/5/23. Interviews conducted with staff revealed R1 moved into the facility under hospice care services due to R1’s health condition and family’s wishes. Facility staff stated R1 was provided care by a hospice nurse and the facility’s staff for all activities of daily living. Per family members R1 had declined in health and needed more assistance. Documents reviewed revealed R1 was under hospice care prior to move into the facility. However, R1 was discharge from hospice on 3/20/23 due to R1 plateauing in health. R1 moved into the facility on 3/22/23 under a new hospice care service agency which provided care from 3/22/23 to 6/28/23. R1 passed away at the facility on 6/28/23 while a hospice care nurse was by R1’s side. Death certificate issued on 2/14/24 notes R1 passed away due to natural causes. Therefore, this allegation is unsubstantiated.

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 allegation: Staff did not change resident’s diaper in a timely manner. It is alleged caregivers were to check R1’s diaper every 2 hours day and night and staff did not do it. Interviews conducted with staff revealed, it is facility’s practice to change residents to check and change residents as needed. Staff stated R1 was being change at least every two hours or more often when necessary. Family members did not have concerns about the care that was being provided by the facility. Facility maintains a monthly diaper change log, per March and April 2023 logs resident was changed an average of 3-4 times in a 24 hour period. There is not enough evidence to say that R1 require changing more than the times noted on the logs reviewed. Therefore, the allegation is unsubstantiated.

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.

Exit interview was conducted with Claudia Almeida and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5