374601302-12-20-2021-08-AS-DPOL-CABN23-20220103090405

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601302
Report Date: 12/15/2021
Date Signed: 12/20/2021 08:05:52 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/27/2020 and conducted by Evaluator Elizabeth Hamilton

COMPLAINT CONTROL NUMBER: 08-AS-20200527110327

FACILITY NAME:	MISSION HOME III		FACILITY NUMBER:	374601302
ADMINISTRATOR:	CURMAK, CEREN		FACILITY TYPE:	740
ADDRESS:	2493 MELBOURNE DRIVE		TELEPHONE:	(858) 560-7676
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92123
CAPACITY:	6	CENSUS: 6	DATE:	12/15/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Caregiver, Maria Susana Barragan		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff neglected resident resulting in an unexplained injury.
Facility staff neglected resident resulting in a pressure injury.
Facility staff neglected resident resulting in scabies.
Facility staff neglected resident resulting in a urinary tract infection.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation visit at the facility. LPA was greeted at the front entrance by Maria Susana Barragan and granted entry after identifying herself. LPA explained the purpose of the visit was to deliver findings for the above allegations.

The Department’s investigation consisted of records reviewed, interviews with residents, staff and outside sources.

On May 27, 2020, it was alleged that on May 19, 2020, facility staff neglected Resident 1 (R1) resulting in an unexplained injury. Interviews with staff revealed that R1 was observed with a red (bloodshot) right eye but no visible head injuries or complaints of pain a few days before a May 19, 2020 hospital visit for a Urinary Tract Infection (UTI). Interviews and records reported R1 was non-ambulatory and needed a two-person assist transitioning in and out of bed with a Hoyer lift. R1 was observed every two hours and staff were not aware of any falls at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

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 3

Control Number 08-AS-20200527110327

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MISSION HOME III	FACILITY NUMBER: 374601302
	VISIT DATE: 12/15/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Interviews with outside sources revealed that after R1 was admitted to the hospital on May 19, 2020, they were diagnosed with a small right frontal hemorrhage (“brain bleed”). Although R1 was diagnosed with this condition, interviews with outside sources confirmed they never observed any visible injuries on R1’s head that would indicate they suffered some sort of head injury while at the facility. Interviews with outside sources confirmed R1 had no known falls at the facility. Interview statements from R1 were consistent in that they never had a fall at the facility. Records reviewed confirmed R1’s diagnosis and showed R1 received services from a home health agency one to two times per week. They had treated a pressure injury to the scalp on or about April 08, 2020, that was observed as “healed” on April 20, 2020; however, no head injuries were notated. Hospital records further indicated there were no visible signs of head injury to account for the brain bleed, which was assessed as stable and did not require surgery. There was insufficient evidence to support the allegation that staff neglect resulted in an unexplained injury to R1.

It was also alleged that on May 19, 2020, facility staff neglected R1 resulting in a pressure injury. Interviews with staff revealed R1 was repositioned every two hours, as they were non-ambulatory and spending most of their time in bed. Any skin tears observed were reported to the home health agency. Interviews with outside sources confirmed R1 had chronic skin issues, including rashes and minor pressure injuries, that were evaluated as either Stage one or Stage two. Interviews with outside sources corroborated facility staff would constantly reposition R1 while in their bed or sitting in their wheelchair to avoid pressure injuries and would report any observed skin issues immediately to the home health agency and to R1’s primary physician. Records reviewed revealed R1 was initially observed with a possible sacral ulcer stage 1-2 upon hospital admission, with a pending wound care consult. The wound consult determined no signs of stage 1 sacral pressure ulcer, and the wound was treated during hospitalization with frequent turning and wound care. Additional records confirmed R1 had a toe wound that was treated March 19, 2020; a wound to middle of back closed and healed on April 7, 2020; wound care treated to the back of scalp on April 09, 2020; and a coccyx pressure injury that healed on April 20, 2020. R1 received outside agency home health visits 1-2 times a week with ongoing skin assessments during this time. There was insufficient evidence to support the allegation that staff neglect resulted in a pressure injury to R1.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20200527110327

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MISSION HOME III	FACILITY NUMBER: 374601302
	VISIT DATE: 12/15/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

It was further alleged that on May 19, 2020, facility staff neglected R1 resulting in scabies. Interviews with staff revealed that R1 had an ongoing rash that was reported to the home health agency and was reported to their primary physician. Interviews with outside sources confirmed R1 had on-going skin issues that included recurring scabies episodes. Records reviewed confirmed R1 had a rash to the back, neck and buttocks that were treated with Clotrimazole. Records further revealed that on May 19, 2020, the rash was thought to be yeast and new medication was prescribed for additional treatment while R1 was hospitalized. There is insufficient evidence to support the allegation that staff neglect resulted in R1’s scabies.

It was also alleged that on May 19, 2020, facility staff neglected R1 resulting in a urinary tract infection (UTI). Interviews with staff revealed that R1 had a catheter that was changed monthly by a home health nurse. R1 had a history of chronic UTIs and was last diagnosed with a UTI in early May of 2020, after a change of condition. Home health was notified, and they were sent to the hospital on May 19, 2020 for evaluation. Interviews with outside sources confirmed R1 had on-going issues with UTIs due to their need for a catheter and that staff would immediately notify the home health agency of any changes to their health. Records reviewed confirmed R1 had a history of UTIs and they had been treated and monitored for UTIs by the home health agency from March 05, 2020 until they were sent to the hospital on May 19, 2020. There was insufficient evidence to support the allegation that staff neglect resulted in R1 developing a UTI.

The Department has investigated the allegations listed above. Based on evidence obtained, including interviews and records reviewed, the above allegations are determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard. An exit interview was conducted with Ms. Barragan and a copy of this report and Licensee/Appeals Rights (LIC 9058 01/16) was provided to the Licensee via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Elizabeth Hamilton
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3