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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 07/11/2022
Date Signed: 07/11/2022 02:02:05 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
06/16/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220616140521
FACILITY NAME:SANTA MARIA TERRACEFACILITY NUMBER:
425850025
ADMINISTRATOR:ENRIQUEZ, SANJUANAFACILITY TYPE:
740
ADDRESS:1405 E MAIN STTELEPHONE:
(805) 925-8713
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:140CENSUS: 97DATE:
07/11/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Amy Bowman, Wellness DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Resident’s diapering needs not met
Facility does not have adequate hygiene supplies
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA requested documents and interviewed staff and residents on 6/22/2022.

On the allegation: Resident’s diapering needs not met. The Reporting Partys (RPs) stated the morning shift finds multiple residents soaked with urine and fecal matter. RPs stated the residents’ diapers are so full, they leak onto their clothing and sheets, soaking them. The facility’s protocol is for all staff to check incontinent residents every 2 hours and change their briefs as needed. The facility’s protocol is alsofor NOC shift to do rounds with the morning shift once the morning shift starts. Based on interviews, in June 2022, residents were observed to be very wet during the morning joint-shift checks. Interviews revealed the residents are soaking wet, their clothing is soaking wet, and the sheets are soaking wet. Multiple staff stated this was an indication that the residents were not changed frequently enough during the NOC shift.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
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-20220616140521
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: SANTA MARIA TERRACE
FACILITY NUMBER: 425850025
VISIT DATE: 07/11/2022
NARRATIVE
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LPA observed multiple photographs of soiled diapers, residents with wet and soiled clothing, and residents laying on wet sheets. Wellness Director stated when she reviewed the photographs, she stated it appeared residents were not changed for over 3-4 hours. LPA reviewed facility’s Plan of Care (POC) Response History documents which indicates staff did not respond to residents incontinence care. Resident 1 was missing a conformation of incontinent need met for one shift on 6/9/22, 6/11/22, 6/12/22, 6/15/22, 6/18/22, 6/19/22, 6/21/22 and 6/22/22. Resident 2 and Resident 3 were missing a conformation of their incontinent needs being met for one shift on 6/11/22, 6/12/22, 6/15/22, 6/18/22, 6/19/22, and 6/20/22. Resident 4 was missing a confirmation of incontinent need met for one shift on 6/11/22, 6/12/22, 6/16/22, 6/18/22, and 6/21/22, Resident 5 was missing a confirmation of incontinent need met for one shift on 6/16/22 and 6/21/22. Resident 6 was missing a confirmation of incontinent need being met for one shift on 6/16/22, 6/17/22, 6/18/22, 6/19/22, and 6/21/22. Resident 7 was missing a confirmation of incontinent need met for one shift on 6/15/22, 6/16/22, 6/19/22, and 6/21/22. Resident 8 was missing a confirmation of incontinent need met for one shift on 6/11/22, 6/16/22, 6/19/22, and 6/21/22. Resident 9 was missing a confirmation of incontinent need met for one shift on 6/11/22, 6/16/22, and 6/21/22. Wellness Director stated they held a meeting with staff to address the diapering issues on 6/14/22 at 2pm for 30 minutes. A follow-up meeting was held on 6/27/22 at 2pm to address the issue again. Wellness Director stated they also addressed the issue with the NOC staff. Based on interviews, record review, and photographs, the allegation is deemed Substantiated at this time.

On the allegation: Facility does not have adequate hygiene supplies. The RP stated staff take briefs and wipes from other residents when residents run out of supplies and the facility staff do not restock them. Multiple staff interviewed indicated hospice residents do not have enough briefs and they take brief from other residents. Multiple staff stated they notify the med tech the resident is out of briefs, but it takes hours for the med tech to restock the briefs. Some staff stated there is also a delay in receiving briefs when notifying hospice more briefs are needed. Wellness Director admitted it’s difficult for hospice residents to get restocked with briefs and wipes. Based on interviews, the allegation is deemed Substantiated at this time.

Exit interview, deficiency cited on 9099-D, report emailed, appeal rights emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220616140521
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: SANTA MARIA TERRACE
FACILITY NUMBER: 425850025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2022
Section Cited
CCR
87625(b)(3)
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87625(b)(3) Managed Incontinence...the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
This requirement is not met as evidenced by:
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Wellness Director held an all staff training on 6/14/22 and 6/27/22 which reviewed team building and incontinent care and provided a sign in sheet to CCL. Wellness Director scheduled Central Coast Home Health for an additional incontinent Care training scheduled on 7/19/22.
The POC was cleared during the visit
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Based on record review, interviews and photographs, the licensee did not ensure residents’ incontinence was properly managed, which poses an immediate health and safety risk to residents in care.
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Type B
07/22/2022
Section Cited
CCR
87307(a)(3)
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87307(a)(3) Personal Accommodations and Services. Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. This requirement is not met as evidenced by:
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Administrator agreed to create a plan to ensure residents’ incontinence care products are reordered and restocked timely.
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Based on interviews, the licensee did not ensure residents’ incontinence care products were readily available to each resident when needed, which poses a potential health and safety 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: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3