336412126-12-10-2021-18-AS-JESL-CB837U-20220131170031

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336412126
Report Date: 12/10/2021
Date Signed: 12/10/2021 11:10:19 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2020 and conducted by Evaluator David Cuevas

COMPLAINT CONTROL NUMBER: 18-AS-20200131164142

FACILITY NAME:	INSPIRATIONS HOME CARE V		FACILITY NUMBER:	336412126
ADMINISTRATOR:	GARCIA, NOELIA		FACILITY TYPE:	740
ADDRESS:	2865 COTTAGE DR		TELEPHONE:	(951) 898-1425
CITY:	CORONA	STATE: CA	ZIP CODE:	92881
CAPACITY:	6	CENSUS: 6	DATE:	12/10/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Licensee, Noelia Garcia		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not seek emergency medical services for resident on a timely manner.

INVESTIGATION FINDINGS:

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On 12/10/21 Licensing Program Analyst (LPA’s) Venus Mixon and David Cuevas conducted an unannounced visit to the above facility to follow up with complaint control 18-AS-20200131164142. LPA’s identified self and were granted permission to enter facility. LPA’s met with Administrator/Licensee Noelia Garcia, who was informed of the purpose of visit.

During this investigation the department conducted facility file review, resident record review, interviews with staff, residents, and witness, conducted observations, and review of pertinent documents.

Allegation #1: Staff did not seek emergency medical services for resident on a timely manner.

Based on interviews, collected statements, and review of medical records and resident’s file it was identified that resident # 1(R1) to have had a history of diabetes that was controlled by proper diet.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200131164142

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: INSPIRATIONS HOME CARE V	FACILITY NUMBER: 336412126
	VISIT DATE: 12/10/2021

NARRATIVE

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Resident was admitted to facility on November 11, 2019, preplacement appraisal reflects no medications needed to treat diabetes. It was not until a doctor’s visit on December 27, 2019, that it was identified that R1 had high blood sugars and medication was prescribed. Additionally, R1 was ordered to monitor blood sugar levels twice a day, a task R1 did independently. Per interviews, elevated readings entered in medication record sheet were values reported by R1 not visually verified by caregivers. Medication for diabetes and sugar level readings were first started on December 27, 2019, per medication sheet. Prior to hospitalization glucose readings for R1 had been noted to be elevated. LPA verified that staff provided medication (metformin) had been dispensed as per physicians’ instructions. On December 12, 2019, staff called medical emergency 911 for observations of a change of condition; as staff noticed resident to be lethargic and weak.

On January 1, 2020, R1 passed away at the hospital; hospital records note cause of death as septic shock, pneumonia, and type A flu. Additionally, reviewed medical records for R1 show that on January 1, 2020, a discussion was documented with R1’s family discussing that R1 had an Acute Respiratory failure due to pneumonia and severe ARDS (Acute Respiratory Distress Syndrome). As such this department deems the allegation of, Staff did not seek emergency medical services for resident on a timely manner to be UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Licensee/ Administrator, Noelia Garcia were a copy of this report was reviewed and provided.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

LIC9099 (FAS) - (06/04)

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