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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005829
Report Date: 09/13/2023
Date Signed: 09/13/2023 04:29:35 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
11/16/2022 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221116131133
FACILITY NAME:MT. SHERROD HOME, LLC.FACILITY NUMBER:
306005829
ADMINISTRATOR:VIVIAN LUIS-ORTIZFACILITY TYPE:
740
ADDRESS:16550 MT. SHERROD CIRCLETELEPHONE:
(714) 839-4417
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
09/13/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Geraldine Doan, administratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff neglected resident resulting in unstageable wounds
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the allegation listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Administrator Vivian Luis-Ortiz was notified of the visit and arrived later to assist. The allegation investigated was present to the administrator.

An initial complaint investigation visit was conducted by LPA Michelle Reed on November 17, 2022, based on the present complaint, which was filed on November 16, 2022. The complaint was investigated by the Department and consisted of resident, staff and family member interviews, a review of facility and resident records, hospital records from MemorialCare Orange Coast Medical Center, records from Excellence Hospice Provider and a tour of the physical plant.

CONTINUED ON FORM LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
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 2
Control Number 22-AS-20221116131133
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MT. SHERROD HOME, LLC.
FACILITY NUMBER: 306005829
VISIT DATE: 09/13/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099

Regarding the allegation that Facility staff neglected resident resulting in unstageable wounds, the following has been concluded: Resident R1 was admitted on November 2, 2021, at the facility as well as onto hospice care on the same day. The hospice terminal diagnosis indicates a history of Muscle Weakness, metabolic encephalopathy and protein-calorie malnutrition upon admission. Per the initial appraisal, R1 is stated to be on regular mechanical soft diet, uses a wheelchair to ambulate and has a foley catheter in place due to a diagnosis of incontinence.

On November 13, 2022, R1 was transferred to MemorialCare Orange Coast Medical Center and admitted with a diagnosis of Altered mental status, Acute cystitis without hematuria and Severe sepsis. At the time of the hospitalization, R1 was discharged from hospice to allow for the transfer, as confirmed by discharge notes dated November 15, 2022. The records provided by the hospice care provider include daily logs dated from August 12, 2022 until November 13, 2022. A minimum of two weekly documented occurrences of wound care are apparent on the notes maintained by hospice staff in their care for the resident. Hospice staff notes indicate that on October 26, 2022, resident was assessed with "no new skin issues, continues with sacral coccyx wound currently stage II (with a history of Unstageable with 100% yellowish slough with redness to surrounding area and redness to perineal area). Site slowly healing with small opening, no signs/symptoms of infection, Private Caregiver may change dressing and reapply Calmoseptine if soiled or dislodged." Photographs on file document the sacro-coccyx wound are present and are consistent with hospice progress notes. Facility caregivers are noted to be "competent and knowledgeable with all treatments" involved in providing wound care to resident. A follow-up hospitalization occurred on December 12, 2022, and includes wound care progress photographs that evidence the slow rate of healing consistent with the failure of nutrition causing the breakdown of tissue due to R1’s condition.

A family member reported satisfaction with the care R1 received and is still receiving at the facility at this time. Staff stated that R1 was readmitted at the facility and is no longer receiving hospice care due to the wound having healed.

Based on the records reviewed and interviews conducted, there was no evidence to support the allegation, therefore the allegation is determined to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2