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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423909
Report Date: 01/20/2023
Date Signed: 01/20/2023 02:24:46 PM

Substantiated


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
11/15/2021 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211115142030
FACILITY NAME:CAMPBELL'S LOVING HOME CARE INC.FACILITY NUMBER:
336423909
ADMINISTRATOR:CHARLES CAMPBELLFACILITY TYPE:
740
ADDRESS:18 NAPOLEON RD.TELEPHONE:
(760) 832-7791
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: 5DATE:
01/20/2023
UNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Elsie Viray, CaregiverTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Resident sustained multiple pressure injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to deliver the findings of the above allegation. LPA met with Caregiver Elsie Viray and toured the facility. The investigation included interviews with staff, medical personnel, Resident One (R1), and a review of facility records and medical documentation. Licensee Charles Campbell arrived inside the facility at the time of visit.

Regarding the allegation, “Resident sustained multiple pressure injuries while in care.” It was alleged that R1 was admitted to the facility on 10/1/2021 with a tiny open sore (pressure wound) but it was healing. On, or about 11/15/2021, R1 had open sores (pressure wound) on the buttocks, ears, ankle, shin and legs.

Through information obtained via confidential interviews and document review, R1 was admitted to the facility on 10/1/2021 with a wound that required positioning/rolling. R1 was residing at an assisted living facility prior to moving to Campbell’s Loving Home. On 9/26/2021 the prior facility conducted an assessment and found that R1 had a pressure wound and required wound care. Wound care was ordered by the physician; however, R1 moved before wound care could begin. The assessment also indicated R1 required “substantial/maximum assistance rolling left/right.”.

On 10/1/2021, five days after the assessment at R1’s prior facility, R1 moved to Campbell’s Loving Home. A review of the pre-admission appraisal did not indicate the presence of a pressure wound. Further, a Needs and Services Plan was not developed by the Licensee at the time of admission. Based on this information, R1 went without wound care from 9/26/21 until 11/12/2021.

Interviews with a medical professional indicated the wound on R1’s coccyx was a stage 1, at best; however, two other wounds had developed. A wound to R1's ankle was seen to develop to a stage 4 and R1's ear had a wound that developed to a stage 3. The Licensee stated the family was contacted to inform them of R1’s condition; however medical treatment was not sought out by the Licensee.

Therefore, based on the investigation, the allegation that Resident (R1) sustained multiple pressure injuries while in care is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Licensee was cited via Title 22.

An exit interview was conducted and a copy of this report was discussed with and provided to Licensee Charles Campbell along with copies of the LIC9099-D, and Appeal Rights.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
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 3
Control Number 18-AS-20211115142030
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: CAMPBELL'S LOVING HOME CARE INC.
FACILITY NUMBER: 336423909
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/03/2023
Section Cited
CCR
87468.1(a)(2)
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Personal Rights. Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Resident was admitted to the facility on 10/1/21. On 11/12/21 resident was seen by A wound care professional to treat the wound. On 11/1/16 Home Health identified two more stage 2 pressure ulcers one with deep tissue injury (buttocks and coccyx). As time progressed resident continued to develop additional wounds and resident’s condition was worsening. During this time staff were aware of these additional wounds being present. This was not met as evidenced by:
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Licensee shall have all staff (including administrator/licensee) trained on resident care and personal rights by a medical professional by POC date.
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Based on interview and record review, the Licensee did not take the neccesary precautions to ensure that R1 did not sustain further pressure wounds. This presents a potential health and safety and personal rights 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: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
11/15/2021 and conducted by Evaluator Jesse Gardner
COMPLAINT CONTROL NUMBER: 18-AS-20211115142030

FACILITY NAME:CAMPBELL'S LOVING HOME CARE INC.FACILITY NUMBER:
336423909
ADMINISTRATOR:CHARLES CAMPBELLFACILITY TYPE:
740
ADDRESS:18 NAPOLEON RD.TELEPHONE:
(760) 832-7791
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: 5DATE:
01/20/2023
UNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Elsie Viray, CaregiverTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff are over medicating resident
Staff did not notify authorized representative of residents change in condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to deliver the findings of the above allegations. LPA met with Caregiver Elsie Viray and conducted a tour of the facility. The investigation included interviews with staff and Resident One (R1), a review of facility documentation, as well as confidential information and interviews. Licensee Charles Campbell arrived inside the facility at the time of visit.

Regarding the allegation, “Staff are over medicating resident.” It was alleged that staff were over medicating R1 to the point that the resident couldn’t keep their eyes open. LPA conducted interviews with staff, and reviewed facility documents. Upon review of the Medical Administration record (MAR) as well as interview with Licensee, it appeared staff was administering medication as ordered by the physician. Additionally, LPA conducted interview with R1’s Primary Care Physician who stated that R1’s physical demeanor could be attributed to their medical condition.

Regarding the allegation, “Staff did not notify authorized representative of residents change in condition.” It was alleged that R1’s POA was not notified of R1’s change in condition. Licensee had regular conversation with R1’s POA as the POA frequented the facility on an average daily basis. Additional interviews provided conflicting information that the responsible parties were not notified of the change in condition. POA who frequently visited was notified, but others were not allegedly notified. Conflicting accounts from confidential witnesses, and the Licensee conclude that there was not sufficient evidence to corroborate this allegation. Therefore, this allegation was deemed to be UNSUBSTANTIATED.

An exit interview was conducted where a copy of this report was discussed with and provided along with a copy of the LIC811 (confidential names list).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3