<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425800643
Report Date: 04/26/2023
Date Signed: 04/26/2023 03:33:11 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/08/2023 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20230308123549
FACILITY NAME:MYDOR'S OPEN GUEST HOME IVFACILITY NUMBER:
425800643
ADMINISTRATOR:JUANITO C. PASIONFACILITY TYPE:
740
ADDRESS:819 MOSS COURTTELEPHONE:
(805) 928-4688
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:4CENSUS: 2DATE:
04/26/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Juanito Pasion, Administrator and Amy Antonio, LicenseeTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not meet resident's incontinence needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA collaborated with Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa on the investigation and interviewed a Witnesses and Responsible Pary on 3/20/23 and 3/27/23, and Staff and clients on 3/13/23, and Administator on 4/24/23. LPA met with Administrator and Licensee and explained the purpose of the visit.

On the allegation: Facility did not meet resident's incontinence needs. It was alleged on 3/8/23 at 7:50 AM Client 1 (C1) was found to be double diapered and saturated through both diapers. C1 passed away on 3/8/23 around 2pm from Cardiorespiratory Failure, Sepsis and a Urinary Tract Infection that the client had for days. LPA and QAS interviewed 2 staff who were present on 3/13/23. Staff 1 stated they checked the resident at 5am, then said they took C1 to the bathroom at 7am, then said that was a different client. S1 said again “At 5am (C1) was wet so I change it” then said “I checked (C1) at 5am and (C1’s) ok and I leave in the bed and another staff comes at 6:30." Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
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 29-AS-20230308123549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MYDOR'S OPEN GUEST HOME IV
FACILITY NUMBER: 425800643
VISIT DATE: 04/26/2023
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
That staff was going to get them up and shower them. Staff observed client unresponsive so called the administrator who said to call 911. LPA asked how often they check on C1 overnight. S1 stated they check on them every 2 hours. LPA asked how they check and staff said “I go in and check” LPA asked to show LPA and S1 walked into the room and turned their head in the direction of the bed. LPA asked how they know if they are wet or not. Staff stated, “oh yeah I go like this” LPA observed S1 to pat the bed. LPA asked if they pat their bottom or top to see if the diaper is full? S1 said yes. LPA asked what diapers they use for overnight. S1 said the overnight diapers and Depends pull ups over them.

LPA and QAS interviewed a second Staff (S2) who stated they went to check on Client 1 and they didn’t wake up, they looked white. The other staff called the Administrator who said to call 911 and so they called 911 and AMR came in 10 minutes. LPA asked what the resident was wearing, staff responded “Pjs, sweatshirt and socks, 2 briefs one white one grey, white on the inside grey on the outside” LPA asked if they checked their diaper. S2 responded “No I didn’t check I smell poo but I can’t not change (C1) because we are calling 911.” All staff stated Client 1 didn’t seem different the night before. They stated C1 ate fine and acted the same and there was no indication of an Urinary Tract Infection (UTI). Administrator takes all staff and client temperatures every morning. LPA reviewed the resident temperature logs for the week and observed C1’s temperature to be between 97.3- 97.6 degrees Fahrenheit.

LPA interviewed C1’s responsible party (RP), who stated they felt the facility took really good care of Client 1. The RP also stated the facility caught a UTI that C1 had last year, based on the smell and color of C1’s urine. The RP was impressed because C1 was not verbal and couldn’t communicate. The RP was not concerned that the facility missed this UTI and stated C1 got UTI’s often and UTI’s were common in C1’s medical history and family medical history.

Based on the investigation, the facility staff stated they “checked” on the incontinent clients overnight just by looking at them across the room, then added that they pat the diapers on the clients when the LPA questioned their response. Staff admitted to regularly double-diapering clients, and admitted to not promptly changing a resident who had a diaper soiled with feces. Based on the information obtained, the allegation Facility did not meet resident's incontinence needs is Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9090-D). An exit interview was conducted, a copy of the report and appeal rights were issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230308123549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MYDOR'S OPEN GUEST HOME IV
FACILITY NUMBER: 425800643
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2023
Section Cited
CCR
87625(b)(3)
1
2
3
4
5
6
7
87625(b)(3) Managed Incontinence
(b)...the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to submit a plan to better check on incontinent residents and submit plan to CCL by 4/27/23. Administrator also agreed to train staff on the plan as well as to not double diaper resident and submit training to CCL with topics covered, name, date, and signature by 5/1/23.
8
9
10
11
12
13
14
Based on interviews, the licensee did not comply with the section cited above when Staff did not ensure incontinent residents were kept dry, which posed an immediate health and safety/personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3