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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602951
Report Date: 07/14/2021
Date Signed: 07/14/2021 12:46:03 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, 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
10/15/2020 and conducted by Evaluator Evangelica Torres
COMPLAINT CONTROL NUMBER: 08-AS-20201015151254
FACILITY NAME:PACIFIC SUNSET - EUREKA SPRINGSFACILITY NUMBER:
374602951
ADMINISTRATOR:MUNAR, VICTORINOFACILITY TYPE:
740
ADDRESS:3131 CRANE AVENUETELEPHONE:
(760) 294-6997
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 2DATE:
07/14/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee Amelia PerlowTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Licensee did not meet resident's care needs
Licensee violated resident's personal rights
Licensee did not follow the admission agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Eva Torres conducted an onsite visit to deliver the findings on the above allegations. LPA identified herself, spoke with Licensee Amelia Perlow, and disclosed the purpose of the visit. The investigation included a review of records and interviews.

It was alleged that the licensee did not meet Resident #1’s (See LIC 811- Confidential Names List for R1) care needs and did not follow the admission agreement. It was further alleged that the licensee violated R1’s personal rights by speaking to them in an uncomfortable manner.

On June 03, 2020, R1 was admitted to the facility. According to R1's admission agreement, the licensee agreed to meet all of R1's activities of daily living. R1's Physician's Report dated May 07, 2020, documented R1 as non-ambulatory and showed that R1 required total assistance with bathing and toileting, as well as stand-by assistance with dressing and grooming, along with medication management. The facility's pre-admission assessment of R1's care needs, dated June 01, 2020, showed that the licensee acknowledged that R1 was non-ambulatory and required assistance with transferring, bathing, dressing, grooming, mobility, toileting, and medication management.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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 6
Control Number 08-AS-20201015151254
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: PACIFIC SUNSET - EUREKA SPRINGS
FACILITY NUMBER: 374602951
VISIT DATE: 07/14/2021
NARRATIVE
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On June 16, 2020, the licensee conducted a reassessment of R1's level of care needs. The reassessment established that overnight supervision was also needed, as the licensee documented that R1 required overnight pain management and incontinent care due to their non-ambulatory status in transferring independently.

In reviewing the facility's license and their Plan of Operation, the facility is licensed for six (6) non-ambulatory elderly residents, at which four (4) out of the six (6) residents may be bedridden. Moreover, the Community Care Licensing Division's (CCLD) records also showed that the licensee has a hospice waiver approval to serve four (4) out of the six (6) residents. According to the facility's Plan of Operation under Care of bedridden Persons, its states, "Residents who are bedridden will received care and supervision appropriate to their needs. Residents will be evaluated for complications of immobility. A service plan will be developed that addresses the needs of the resident and evaluates quarterly. Staff scheduling will accommodate the resident's needs, requiring turning and repositioning to tenure turning is taking place at least every two hours or more often as required. One-on-one staffing will be provided if it is determined to be needed by the resident." In reviewing the facility's hospice plan, it states that the licensee will develop a plan that describes the licensee's responsibilities including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident's physician, and the resident's responsible person(s), at which the description shall include the type and frequency of the tasks to be performed by the facility.

On August 30, 2020, R1 was transported to the hospital due to an altered state of mind and discharged the next day with new medication orders. The review of the discharge records did not reveal R1 had any pressure injuries. On or about September 01, 2020, R1 was assisted to the living room to sit in a recliner by the facility staff. While R1 was sitting in the recliner talking to their responsible party, they pressed their call alert alarm for assistance. As staff did not respond, R1's responsible party called the licensee to inform them that R1 needed help off the recliner. Upon the licensee returned to the facility, they asked R1 if they were stuck in the recliner. R1 replied they were not stuck on the recliner but needed assistance. The licensee responded by stating, "If you are not happy here, you can leave, and go to another licensed facility." An interview with the licensee confirmed that the statement was said to R1 while they sat in the recliner.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20201015151254
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: PACIFIC SUNSET - EUREKA SPRINGS
FACILITY NUMBER: 374602951
VISIT DATE: 07/14/2021
NARRATIVE
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On September 11, 2020, R1 was again transported to the hospital due to their increase in weakness. According to the hospital's records, the physician conducted a physical examination of R1's state and skin. The assessment revealed no abnormalities except that R1 was present with a fever, abdominal pain, and weakness. On September 16, 2020, R1 was discharged from the hospital and returned to the facility.

On September 18, 2020, R1 was again transported to the hospital due to chronic pain. While in the hospital, R1 was assessed, and the physical exam revealed no abnormalities except for mild distress due to pain. On September 22, 2020, R1 was reexamined, at which it was observed that R1 had ulcers on their lower back. R1 was discharged from the hospital with the recommendation of receiving hospice services.

On September 22, 2020, R1 was evaluated and admitted to hospice. According to the comprehensive assessment conducted by hospice, dated September 22, 2020, it showed that R1 had a change in condition, as the evaluation revealed that R1 required maximum assistance with all their activities of daily living, such as transferring, dressing, grooming, bathing, ambulation, and medication management. Furthermore, the hospice also documented that they observed three small blisters located in the sacrum and coccyx, at which hospice provided medication and repositioning training to the facility staff. On September 23, 2020, hospice documented R1 as bedbound, assessed R1's skin, and provided training to the facility staff. On September 25, 2020, hospice conducted a routine visit and observed R1's coccyx area to be pink. Hospice again provided the facility staff with training on meeting R1's care needs. On September 30, 2020, hospice made a follow-up visit and observed multiple small red areas around the coccyx region. Hospice again provided training and instructed the facility staff to reposition the resident every two hours.

On the same day, at approximately 09:50 AM, the licensee reported another change in condition and requested a modification to R1's medication. Hospice provided training in meeting R1's medication needs, at which the licensee refused and demanded hospice to meet all of R1's medication needs. As the agency medical professional attempted to provide consultation on the responsibilities of the hospice agency, the licensee ended the phone conversation by hanging up the phone on them. However, an interview with the hospice agency confirmed that the licensee did complied R1’s medication. On September 30, 2020, at about 07:44 PM, hospice called the facility to conduct a welfare check on R1. Hospice spoke with the licensee and inquired about R1's repositioning needs. The licensee replied, "Don't blame me or us for the skin breakdown; it's from the hospital."

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20201015151254
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: PACIFIC SUNSET - EUREKA SPRINGS
FACILITY NUMBER: 374602951
VISIT DATE: 07/14/2021
NARRATIVE
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As hospice staff again attempted to provide consultation to the licensee, the licensee ended the phone conversation once more by hanging up the phone on them. On October 01, 2020, hospice conducted another routine visit for wound management and found R1 to be in pain, agitated, and crying out, "help me." Hospice again provided facility staff with training in meeting R1's care needs. However, the records showed that the licensee was unwilling to accept hospice training in meeting R1's care needs. On October 03, 2020, hospice made another routine visit for wound management and observed R1 with an unstageable pressure injury located on their coccyx. Hospice again documented that they provided the facility staff with training. On October 04, 2020, hospice conducted another routine visit for wound management and observed a new skin tear located on the sacral area, at which hospice again provided repositioning training every two hours to facility staff. On October 08, 2020, R1 passed away with a cause of death documented as Chronic Obstructive Pulmonary Disease with the contributed factor recorded as Encephalopathy. Though staff interviews were inconsistent, hospice’s records and their interviews supported the allegations.

Based on the review of records and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is SUBSTANTIATED. California Code of Regulations (Title 22, Division 6), deficiencies are cited on the attached LIC 9099D.

An exit interview was conducted with Licensee Amelia Perlow, and their signature on this report was obtained. The Licensee/Appeal Rights (LIC 9058 01/16) and a copy of this report was emailed to them. A return email from the license will confirm receipt of documents.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20201015151254
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: PACIFIC SUNSET - EUREKA SPRINGS
FACILITY NUMBER: 374602951
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2021
Section Cited
CCR
87606(f)(2)
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Care of Bedridden Residents: To accept or retain a bedridden person, a facility shall ensure the following: Each bedridden resident's record includes sufficient documentation to demonstrate that the facility is meeting the needs of the individual resident. This requirement was not met as evidence by:
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Licensee stated that will seek outside training in ensuring sufficient documentation is demonstrated by the facility in meeting resident's needs. The licensee will forward the proof that they completed the training to CCLD by the POC due date of 07/30/21.
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Based on conducted interviews and the review of the records, the licensee did not sufficiently demonstrate through documentation that R1’s rotation needs were being met by staff at all times, which posed a potential health risk to one out of four residents in care.
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Type B
07/30/2021
Section Cited
CCR
87507(j)
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Admission Agreements: No licensee shall enter into any continuing care contract with any person without approval by the Department in accordance with Health and Safety Code, Chapter 10, Division 2. This requirement was not met as evidenced by:
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Licensee stated that they will amend their admission agreement to include the require language behind meeting all resident's needs. The licensee will forward the amended agreement to CCLD by the POC due date of 07/30/21.
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Based on records reviewed and interviews conducted, the licensee did not follow their agreement in meeting all of R1’s activities of daily living needs, which posed a potential health risk to one out of four 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: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20201015151254
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: PACIFIC SUNSET - EUREKA SPRINGS
FACILITY NUMBER: 374602951
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2021
Section Cited
CCR
87468.1(a)(3)
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Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by:
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Licensee stated that will seek outside training on personal rights. The licensee will forward the proof that they completed the training to CCLD by the POC due date of 07/30/21.
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Based on records reviewed and conducted interviews, the licensee humiliated R1 by speaking to them in an uncomfortable manner, which posed a potential mental health risk to one of four 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: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6