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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426054
Report Date: 09/12/2023
Date Signed: 09/12/2023 03:32:14 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
09/14/2022 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220914185645
FACILITY NAME:CALEO BAY ALZHEIMER'S SPECIAL CARE CENTERFACILITY NUMBER:
336426054
ADMINISTRATOR:WILKIN, RONDAFACILITY TYPE:
740
ADDRESS:47805 CALEO BAY DRIVETELEPHONE:
(760) 771-6100
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:66CENSUS: 51DATE:
09/12/2023
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Executive Director, Maria ArriagaTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Resident sustained a fractured femur as a result of staff neglect.
Staff did not seek immediate medical treatment for resident.
Staff do not inform resident's authorized person of incidents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to deliver findings on the above allegations. LPA met with Executive Director, Maria Arriaga, who was informed of the purpose of the visit. During the course of the investigation, the department conducted interviews, records reviews and toured the facility.

Regarding allegation, “Resident sustained a fractured femur as a result of staff neglect.” It was alleged that Resident #1 (R1) had sustained a femoral fracture at the facility on or around 09/06/2022, and that the injury was caused by caregivers at the facility. Hospital records note R1 was transported to the hospital on 09/09/2022. Radiology Report dated 9/9/2022, revealed R1 was diagnosed with a Displaced Intertrochanteric Fracture of the Right Femur.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
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 9
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
09/14/2022 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220914185645

FACILITY NAME:CALEO BAY ALZHEIMER'S SPECIAL CARE CENTERFACILITY NUMBER:
336426054
ADMINISTRATOR:WILKIN, RONDAFACILITY TYPE:
740
ADDRESS:47805 CALEO BAY DRIVETELEPHONE:
(760) 771-6100
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY:66CENSUS: 51DATE:
09/12/2023
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Executive Director, Maria ArriagaTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Staff did not follow doctors orders regarding resident care
INVESTIGATION FINDINGS:
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On 9/12/2023 Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to deliver findings on the above allegations. LPA met with Executive Director, Maria Arriaga, who was informed of the purpose of the visit. During the course of the investigation, the department conducted interviews and records reviews.

Regarding “Staff did not follow doctor’s orders regarding resident care”, it was alleged that R1 had doctor’s orders for fluid (F1) as a hydration supplement. It was alleged staff were not providing this to R1 at required intervals. LPA reviewed R1’s facility medication list dated September 2022 that noted F1 was to be provided three times daily and was orders 7/22/2020 and again on 7/27/2020. LPA requested MARS sheet for R1 for September 2022 and found F1 had been accounted for. R1 was hospitalized on 9/9/2023 for an unrelaed matter. LPA reviewed hospital diagnosis records date 9/9/2023 and found there was no diagnosis of dehydration for R1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 18-AS-20220914185645
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: CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER
FACILITY NUMBER: 336426054
VISIT DATE: 09/12/2023
NARRATIVE
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LPA interviewed S4 who stated that staff was documenting when F1 was being given and that staff were providing this for the resident. Therefore, based on the above information LPA was unable to corroborate the allegation that staff was not provided with F1. Therefore, the allegation is unsubstantiated .

Findings that are unsubstantiated mean that although the allegation may be valid, the preponderance of the evidence standard has not been met.

An exit interview was conducted with Executive Director, Maria Arriaga, where this report was reviewed and provided to them.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 18-AS-20220914185645
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: CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER
FACILITY NUMBER: 336426054
VISIT DATE: 09/12/2023
NARRATIVE
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The department interviewed staff who stated they are assigned a “round” described as an assignment of residents for the day. The staff stated there are six (6) “rounds” with a staff assigned to each “round”. Staff #1 (S1) stated that on 09/06/2022 the facility was “short staffed” and only had four (4) caregivers to cover the six (6) rounds. Staff #2 (S2) confirmed that R1 was one of the residents assigned to their “round” on 09/06/2022.

Staff interviews revealed conflicting information. S1 reported they asked S2 to assist with R1. S1 reported they “struggled” lifting R1 to a standing position because R1 was “putting up a fight”. S1 reported R1 had been combative, and after changing had been “tugging” on the staff’s arm and as a result R1 tripped over the floor transition strip in the restroom and fell. S1 reported trying to catch R1, but due to the momentum of the fall, S1 fell “on the side” of the resident. S1 provided conflicting information when they were re-interviewed. S1 later stated they had fallen partially on R1’s body but denied placing their full body weight on R1.

Staff interview with witness revealed, S2 assisted S1 with changing R1. It was reported S1 had “rushed” the resident, “pushed” the resident with their hand which caused the resident to trip over S1’s leg and fall onto their back. It was further reported, S1 tried to catch R1 but R1 was “too heavy” and S1 ended up falling with their “whole body” on top of R1’s leg, and R1 immediately screamed.

A review of facility progress notes dated 9/6/2023 1:46 p.m, revealed a third version of what occurred, which was that S1 reported that R1 had fallen on their right knee, causing the resident to fall and be injured. A review of text messages starting 9/11/2022 from S1 to S2 revealed S1 making several attempts to convince S2 to “be on the same page” and report that R1 was being combative and fell over the floor transition strip.

Based on the totality of evidence, from interviews conducted and records review; the allegation resident sustained a fractured femur as a result of staff neglect, is substantiated.

An immediate civil penalty of $500 is being assessed in accordance with Health and Safety Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident is pending and under review by the Department.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 18-AS-20220914185645
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: CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER
FACILITY NUMBER: 336426054
VISIT DATE: 09/12/2023
NARRATIVE
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Regarding allegation, “Staff did not seek immediate medical treatment for resident.” R1 fell on 09/06/2022. Interviews with staff revealed, R1 screamed immediately after the fall. Staff reported seeing R1 in pain with a swollen knee and leg. This incident was reported to Staff #3 (S3) who assessed R1 and then called hospice. Hospice notes dated 9/6/2022 revealed hospice staff assessed R1. A mobile x-ray unit was requested and came out to the facility on 09/07/2022. The x-ray was completed for R1’s knee, as staff were told, R1 fell on their knees. Radiology report dated 9/7/2022 revealed, the x-ray was negative for an injury to R1’s knee.

Staff interviews revealed R1 was still observed to be in pain after the x-ray. R1’s POA, then insisted on R1’s foot and hip being x-rayed. Additionally, Staff #4 (S4) documented on facility progress notes 9/8/2022 R1’s upper right thigh in an “awkward” position. On 09/09/2022, a second X-ray was conducted. Radiology report dated 9/9/2022 revealed, the x-ray showed a right femoral fracture. R1’s doctor requested R1 be sent out for possible surgery.

A total of five different staff interviews, revealed, they believed R1 was in pain because R1 appeared “pale” in the face and had swelling and redness on their knee and leg. A review of progress notes, dated between 9/06/2022 and 09/09/2022, corroborated that R1 was changed and transferred to and from their recliner and had been observed to be in pain.

Therefore, from the time of the fall on 09/06/2022 to 09/09/2022, three (3) days had elapsed where the resident was observed to be in pain and staff did not seek medical attention. Therefore, the allegation is substantiated.

Regarding allegation “Staff do not inform resident's authorized person of incidents”, it was alleged that resident had fallen at the facility several times and that the resident’s POA had not been informed about some of the falls when they occurred. LPA conducted a file review of the facility and found that falls documented on hospice progress notes for 6/3/2022, 3/18/2022, 2/24/2022 and 2/21/2022 had not been reported to the department. LPA also found that fall resulting in a femoral fracture on 9/6/2022 had not been reported until 9/14/2022, past the 7-day reporting requirement. It was also found during department investigation that S1 had not given accurate account of events for R1’s fall on 9/6/2022. It was only found during this investigation and through re-interviewing S1 that S1 had fallen on top of R1. Therefore, based on this information the allegation is substantiated

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 18-AS-20220914185645
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: CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER
FACILITY NUMBER: 336426054
VISIT DATE: 09/12/2023
NARRATIVE
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Substantiated findings mean that the preponderance of the evidence standard has been met.

Deficiencies were cited for substantiated allegations according to the California Code of Regulations Title 22 Division 6 Chapter 8. Plans of correction were documented and created with Executive Director, Maria Arriaga, along with deficiencies on an LIC9099-D page.

An exit interview was conducted with Executive Director, Maria Arriaga, where this report along with civil penalty page LIC421IM, LIC9099-D pages, and appeal rights were reviewed and provided to them.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 18-AS-20220914185645
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: CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER
FACILITY NUMBER: 336426054
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/13/2023
Section Cited
CCR
87468.2(a)(8)
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(a) In addition…all of the following personal rights:(8) To be free from neglect…physical, or sexual abuse.This requirement was not met as evidenced by:
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The administrator agreed to hold an all staff training on 9/21/2023, where staff will be trained on resident, changing, challenging behavior, and personal rights.
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Based on interviews and records review,S1 was neglectful while changing R1, by pushing R1 and falling on top of R1’s leg resulting in a fracture. This poses an immediate health, safety or personal rights risk to residents in care.
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The licensee agreed to send the training material to the LPA by the POC due date and notify the LPA when the training is completed on 9/21/23.
Request Denied
Type A
09/13/2023
Section Cited
CCR
87465(a)(1)
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(a) A plan for incidental medical...care shall be developed...(1)The licensee shall arrange, or assist in arranging, for medical...care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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The administrator agreed to send the LPA training material they will use with staff for emergency scenarios and assessing residents. This will be sent
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Based on interviews and records reviews, R1 did not receive appropriate medical attention for fractured until (3) days after. This was due to S1 disseminating inaccurate statements. This poses an immediate health, safety or personal rights risk to residents in care.
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to LPA by the POC due date. The Administrator agreed to send notification to the LPA when the training is completed on 9/21/23.
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: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 18-AS-20220914185645
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: CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER
FACILITY NUMBER: 336426054
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
09/19/2023
Section Cited
CCR
87221(a)(1)
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(a) Each licensee shall furnish...(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This requirment was not met as evidenced by:
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The licensee agreed to send the LPA a self certified statement on their understanding of reporting requirments and when to
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Based on interviews and records review it was found incident for R1 was reported past 7 days and reported inaccurate occurence to responsible party. This poses an potential health saftey or personal rights risk to residents in care.
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report a resident fall. This is due by the POC due date the LPA.
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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: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 9 of 9