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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002745
Report Date: 08/11/2022
Date Signed: 08/11/2022 11:22:49 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/21/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20220321145705
FACILITY NAME:NEW VISION SERVICES SENIOR CARE 3FACILITY NUMBER:
455002745
ADMINISTRATOR:WATKINS, AUSTINFACILITY TYPE:
740
ADDRESS:2800 SQUIRE AVETELEPHONE:
(916) 224-2206
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:6CENSUS: 4DATE:
08/11/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lindsey Domreis- house managerTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Family was not notified of residents’ pressure ulcer - SUBSTANTIATED
Facility is not following doctors ordered diet - SUBSTANTIATED
INVESTIGATION FINDINGS:
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08/11/2022 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with house manager Lindsey Domreis. The purpose of this visit was to deliver the results of the complaint investigation of the above allegations. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves. In addition, LPA was screened by facility staff.

During the course of the investigation house manager and 4 staff were interviewed. LPA obtained the following documents to investigate the above allegations: LIC602 Physician's Report, Admission Agreement, LIC603A Resident Appraisal form, List of medications, Staff Roster, Notice of Inability to Continue Care, Text messages, photographs of pressure ulcer and example meal, home health nursing notes.
Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
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 5
Control Number 25-AS-20220321145705
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: NEW VISION SERVICES SENIOR CARE 3
FACILITY NUMBER: 455002745
VISIT DATE: 08/11/2022
NARRATIVE
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Family was not notified of residents’ pressure ulcer – SUBSTANTIATED

LPA review of documents revealed that starting on 02/09/2022 R1 was being treated in the facility by home health for a stage 2 pressure injury. Various text messages received between 02/05/2022 – 02/07/2022 confirmed that the family was aware that R1 had an on-going spot that was visible during R1’s admission to the facility. On 02/05/2022 the family was notified that the spot opened up and the facility had been treating it for 1 week. At this time family stated they thought the facility would inform them if they were treating R1 for a pressure injury.

During staff interviews it was learned that when R1 moved into the facility they already had the pressure injury and the family was aware of it.

House manager stated R1’s family member was present in the bathroom when the facility did R1's physical assessment. When R1 moved in R1 had a wound on their hip that had a band aid on it. The family supplied a cream to put on the wound. The wound healed and came back a few times. The family took R1 back to see their doctor in February 2022 and home health was ordered for R1. Administrator texted the family and notified the wound was getting bad again and was not healing. The family said, “I wish you would have told me sooner.”

It was determined that although the family was aware that R1 had an ongoing issue with the pressure wound, the family was not notified in a timely manner that the wound had opened up until 1 week after discovery by the facility therefore the allegation is substantiated.

Continued on LIC9099-C

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20220321145705
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: NEW VISION SERVICES SENIOR CARE 3
FACILITY NUMBER: 455002745
VISIT DATE: 08/11/2022
NARRATIVE
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Facility is not following doctors ordered diet – SUBSTANTIATED

LPA review LIC602 Physicians Report dated 12/31/2021 revealed that R1 required a special diet with thickened fluid, pureed diet. Text from family states that LIC602 issued by R1’s physician had “NO” checked in the column for special diet. Daughter took the LIC602 back to the doctor the same day for correction, daughter planned to pick up the LIC602 on 01/05/2022.

LPA review of home health nursing notes for R1 revealed that the RN had reviewed a signed order in the facility from R1’s physician that required a pureed diet and thickened fluids. RN confirmed this requirement during telephone call with R1’s physician. RN stated that facility staff informed RN that R1’s DPOA had OK’d for soft foods. RN was not provided any documentation to confirm this.

Interview with RN revealed that RN witnessed facility staff feeding R1 cottage cheese and halved strawberries with thin fluids. RN asked why they were not following R1’s diet that was ordered by MD. Facility staff said that R1's family ok'd for R1 to have a soft diet. RN asked the facility staff if R1 had anything in writing saying so, staff said "NO." RN states they followed-up with R1’s family and family deny giving the facility permission in following a different diet than what has been ordered.

Three of four staff interviewed stated that they were aware that R1 required a pureed diet. One staff stated that R1 required a soft mechanical diet. Two staff stated that they provided R1 with a pureed diet. One staff stated they work nights and don’t provide food. One staff stated that they provided R1 with soft foods.

Continued on LIC9099-C

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20220321145705
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: NEW VISION SERVICES SENIOR CARE 3
FACILITY NUMBER: 455002745
VISIT DATE: 08/11/2022
NARRATIVE
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House manager stated that the physician had initially filled out NO to special diet on the LIC602 Physician's Report. A family member then took the Physician’s Report back to R1’s doctor and the doctor changed the form rather than filling out a new form. The date that the doctor made this change is unknown.

LPA reviewed a black and white photograph with three bowls, one containing cubed vegetables, the second contains beans, and the third contains an unknown substance. There are handwritten notes in the margins that state “When giving R1 meals they need resemble this picture. She always needs a main, a side, and a veg. R1 can eat soft foods whole like the beans and mixed veggies. Per family members.” The photograph is dated 01/05/2022.

House manager stated that she and a family member made the meal together as an example of what R1 should eat and the house manager took a photograph and made the notes.

It was determined that even though the family indicated that it was OK for R1 to have a soft diet the facility always has to follow the LIC602 Physicians Report that prescribes the required diet for the resident. LPA requested the LIC602 Physician’s report from the facility three times and all copies that were provided to LPA by the facility indicate that R1 requires a pureed diet. RN witnessed staff giving R1 soft food which is not the prescribed diet for R1. The allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was emailed to house manager Lindsey Domereis, and administrator Melissa Johnson.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20220321145705
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: NEW VISION SERVICES SENIOR CARE 3
FACILITY NUMBER: 455002745
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2022
Section Cited
CCR
87466
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87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
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Administrator agrees to review regulation and submit a statement of understanding. Additionally, Administrator to submit a plan of how facility staff will notify physician and responsible party of resident changes in a timely manner.
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Based on LPA interviews and records review it was determined that although the family was aware that R1 had an ongoing issue with the pressure wound, the family was not notified in a timely manner that the wound had opened up until 1 week after discovery by the facility which poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 8/25/2022.
Type B
08/25/2022
Section Cited
CCR
87555(b)(7)
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87555 General Food Service Requirements - (b) (7) The following food service requirements shall apply: Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by:
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Administrator agrees to conduct staff training on the requirement that staff follow Physician’s Orders when a resident has a prescribed diet. Administrator to send in-service curriculum and staff attendance sheet with signatures to LPA Knight as proof of correction.
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Based on LPA interviews and records review it was determined that the facility was not adhering to the resident’s prescribed pureed diet as listed on the LIC602 Physicians Report on file at the facility which poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 8/25/2022.
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: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5