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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002535
Report Date: 07/01/2021
Date Signed: 07/01/2021 09:20:46 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/24/2021 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210324133018
FACILITY NAME:PARADISE RESIDENTIAL HOMEFACILITY NUMBER:
306002535
ADMINISTRATOR:NOEMI FIGUEROAFACILITY TYPE:
740
ADDRESS:546 N. WRIGHTWOOD DRIVETELEPHONE:
(714) 516-2750
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: DATE:
07/01/2021
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Yulisa FigueroaTIME COMPLETED:
09:10 AM
ALLEGATION(S):
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facility retained resident with unstageable pressure injuries
facility failed to seek timely medical treatment.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of delivering findings regarding complaint allegations listed above. LPA Martinez arrived at facility and was greeted at the door by Assistant Administrator Yulisa Figueroa. LPA met with Assistant Administrator and explained the nature of the visit.

The following was concluded:
The Department received a complaint that the “facility retained resident with unstageable pressure injuries” and that “facility failed to seek timely medical treatment.” The investigation included record review and interviews with pertinent parties.
Resident#1 (R1) moved into Paradise Residential Home facility on 1/1/2021. When R1 moved into the facility, they were under the care of CalOptima Health who contracted Preferred Excellent Care (PEC) Home Health to provide colostomy care. The PEC Nurse trained facility staff to provide colostomy care for R1, and

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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 5
Control Number 22-AS-20210324133018
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PARADISE RESIDENTIAL HOME
FACILITY NUMBER: 306002535
VISIT DATE: 07/01/2021
NARRATIVE
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once they were proficient, the PEC nurse scaled their visits back to once a month to check on R1 vital signs and conduct a head to toe assessments. Interviews conducted concluded that the PEC nurse instructed facility staff to contact them with any new medical issues or changes in R1’s condition.

The investigation revealed that in Mid-February 2021, staff noticed the developments of wounds on R1 heels and reported it to Administrator Noemi Figueroa. At the time, Administrator Noemi Figueroa noticed R1 was rubbing their heel against the mattress, causing it to become red. The observations were reported to Cal Optima Home Health. Administrator Noemi Figueroa was advised to reach out to R1’s responsible party and inquire about getting an air mattress. Although she could not recall the exact date, Administrator Figueroa reported that R1’s family provided a new air mattress sometime after February 26, 2021. Administrator Noemi Figueroa stated that R1 continued to rub their heels on the mattress after receiving the new air mattress.
Administrator Noemi Figueroa first noticed R1’s heel injuries on March 4,2021 and she described them as red with blistering. Administrator Figueroa admitted she did not call the home health to notify them of R1 wounds and home health had not been out to the facility to visit R1. Administrator Noemi Figueroa and facility staff were aware of R1 developing and worsening wounds on both of their heels and did not report the wounds to R1 home health nurse or treating physician.

The investigation revealed that on March 8,2021, a PEC nurse went out to the facility to conduct their monthly assessment on R1, and that during the examination the PEC nurse discovered the wounds on R1’s right and left heels. Both wounds discovered by the PEC nurse were black in color and was identified as unstageable pressure injuries.

Interviews with interviewees concluded that although staff tried to mitigate R1’s wounds by elevating their feet, changing their mattress and putting heel booties on, the wounds continued to worsen. Three of three Interviews with Interviewees concluded that R1’s heel wounds were never reported to home health officials by facility staff. From approximately February 26, 2021 to March 8, 2021 Administrator Figueroa did not seek medical attention for R1’s worsening wounds.

Upon notice of the unstageable pressure injuries, Administrator Noemi Figueroa reported that she did not send R1 out to receive medical treatment as the home health nurse had reached out to R1’s primary care physician

Continued on LIC9099-C
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20210324133018
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PARADISE RESIDENTIAL HOME
FACILITY NUMBER: 306002535
VISIT DATE: 07/01/2021
NARRATIVE
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who advised the home health nurse to begin treatment. No request for exception was received by the Department in order to retain a resident with a prohibited health condition of unstageable pressure injuries. Administrator Noemi Figueroa did not report that she notified the home health nurse of the condition’s prohibited status.

Based on the preponderance of evidence gathered through multiple interviews and documents obtained; the allegation “Facility retained resident with unstageable pressure injuries” and “facility failed to seek timely medical treatment,” has been met; Therefore, the allegations listed above are deemed to be SUBSTANTIATED.

The facility is being cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted with Assistant Administrator Yulisa Figueroa, and a copy of this report, along with LIC9099-D, Appeal Rights, and the LIC 811, identifying confidential names was left at facility.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20210324133018
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PARADISE RESIDENTIAL HOME
FACILITY NUMBER: 306002535
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2021
Section Cited
CCR
87615(a)
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Prohibited Health Conditions: (a)Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: This requirement is not being met as evidenced by; On 3/8/2021, a visiting Home health Nurse assessed resident and
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Licensee will develop and submit a training plan and include who will provide the training, topics included in the training, hours of training, and who will attend the training. Training must be relevant to the citation.

Licensee to submit to LPA by POC due date.
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observed 2 unstageable pressure injuries to the left and right heel. Administrator Noemi Figueroa did not contact department to obtain exception waiver and retained resident in the facility. This poses an immediate Health and Safety Risk to residents in care.
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Type A
07/02/2021
Section Cited
CCR
87466
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Observations of the Residents: 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 deterriotion of mental
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The licensee shall ensure that any changes of condition will be reported to resident’s physicians and the responsible party. The licensee shall ensure that all staff members will receive in-service training on seeking medication attention in a timely manner concerning residents in care.
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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. This requirement is not met as evidenced by; on 3/4/2021, Administrator Noemi Figueroa and facility staff were aware of R1
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Licensee to submit proof to LPA by POC due date.
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: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20210324133018
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PARADISE RESIDENTIAL HOME
FACILITY NUMBER: 306002535
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2021
Section Cited
CCR
87466
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This is continued from previous page, note this is not an additional citation.
developing and worsening wounds on both of his heels and did not report the wounds to R1 home health nurse or treating physician. This poses an immediate Health and Safety 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: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5