STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING FACILITY EVALUATION REPORT ?ll-$3274 $121133: CORPORATE Damon FACILITY NAME: COURT YARD ESTATES FACILITY NUMBER: 198205250 ADMINISTRATOR: ZAFIRIS . FACILITY TYPE: 740 ADDRESS: 27104 FOND DU LAC ROAD TELEPHONE: (310) 392-9196 RANCHO PALOS VERDES STATE: GA ZIP CODE: 90275 CAPACITY: 6 CENSUS: 0 DATE: 021?20/201 9 TYPE OF VISIT: Case Management UNANNOUNCED TIME BEGAN: . 12:17 pm . MET WITH: TIME COMPLETED: 01:30 PM NARRATIVE This report was mailed to licensee via certified mail on 21202019. On March 22, 2018, the Department concluded a complaint investigation, which alleged that the Licensee failed to keep the facility free of vermin (rats). During the Investigation, the Department determined that the Licensee failed to provide adequate care and supervision to R1, which resulted in R1 sustaining numerous pressure injuries, developing severe sepsis, and exposure to rats. On January 14, 2019 the Licensee was cited for violating California Code of Regulations (CCR) Title 22, 87466 Observation of the Resident, for neglect by failing to document and bring changes to the attention of R1 '5 physician and responsible person; CCR Title 22 87615 Prohibited Health Conditions for retaining R1 with stage 3 and 4 pressure injuries; CCR Title 22 Personal Rights 87468.2(a) (8)10r neglect for failing to uphold resident?s rights; and CCR Title 22 forfeiting to report the hospitalization and death of R1 to the Department. The investigation revealed that R1 a had history of hospitalization and skilled nursing facility admissions prior to transfer before being transferred to Courtyard Estates in February of 2016. Basedon the physician's report dated February 22, 2016, R1 had Dementia; Osteoarthritis; required assistance with all Activities of Daily Living was incontinent of both bladder and bowel; and . was free of skin breakdown. R1 received hospice and palliative care from February 2016 to August 2017. Based on the hospice discharge report, she was discharged from hospice care because she was eating better, no longer required oxygen, and no discernable skin problems-were noted. 25 . . . Wenvrsos's NAME: Myriam Luge TELEPHONE: (323) 930-4932 LICENSING EVALUATOR NAME: Cheraki Davis TELEPHONE: (323) see-4935 LICENSING EVALUATOR SIGNATURE: DATE: 02/2022019 I acknowledge receipt of this form and Understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02(20/201 9 This report must be available at Child Care and Group Home facilities for public review for 3 years. Ltcans (PAS) - (05:04} 1 ?f 1 STATE OF - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CARE LICENSING DIVISION FACILITY EVALUATION REPORT (Cont) cow Regions] of?ce; was CORPORATE on #130 MONTERY PARK, CA 81754 FACILITY NAME: COURT YARD ESTATES FACILITY NUMBER: 198205250 VISIT DATE: 02/20/2019 NARRATIVE On February 20, 2018 R1 was hospitalized and diagnosed with severe sepsis, pneumonia and toxic encephalopathy. According to the American Journal of Nursing, sepsis is ?the presence in tissues of harmful bacteria and their toxins, typicaiiy through infection ofa wound.? Per the National Institutes of Health, toxic encephalopathy is ?used to indicate brain dysfurrction caused by toxic exposure in addition, R1 was diagnosed with approximately 10 pressure injuries. According to the Mayo Clinic, "pressure injuries (pressure ulcers) are injuries to skin and underlying tissue resulting from prolonged pressure on the skin The pressure injuries were staged as followed: (snowmen-hummus 10 1.Left hip? Deep tissue pressure injury measuring 6 7 end dark- maroon discoloration with partial 11 thickness skin loss, multiple blisters, periwcund intact, smali serosanguinous discharge (consisting 12 of serum and blood no malodor 13 2.3acral region? Unstageable measuring 7 8 0.4 cm- full thickness skin loss, wound base 40% yeiiow to tan in color and black necrosis, serosangninous disoharge minimal, no malodor. 16 Periwound is intact, no signs and of abscess formation. 17 3.Left heel- Stage 3 - Deep tissue pressure injury measuring 6 8 cm- Appears to be ruptured 13 blister, wound base very dark maroon almost black (40% of the wound base), serosanguinous 19 discharge minimai, no malodor, periwound intact. 20 4.Left foot ?ist metatarsal-Deep tissue pressure injury measuring 6.5 3 cm- partiai thickness skin 21 loss deep maroon discoloration with partial thickness skin toss, no discharge, periwound intact. metatarsal- Deep tissue pressure injury measuring 2.5 2 cm maroon discoloration 24 with partial thickness skin loss, no discharge, periwound intact. 25 6.Left foot 5"1 metatarsal~ Deep tissue pressure injury measuring 3.5 3 cm? maroon discoloration, 26 no bogginess to the wound paipation, no discharge, periwound intact . 27 7.Left laterai thigh Stage 2 measuring 3.5 3 cm- intact, clear ?uid filled blisters. NAME: Myriam Luge TELEPHONE: (323) 9304932 LICENSING EVALUATOR NAME: Cheraki Davis TELEPHONE: (323) 980-4935 LICENSING EVALUATOR SIGNATURE: B- . . DATE: 0212012919 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02i2 0f201 9 LICBUQ (FAB) (08014} Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY GARE LICENSING DIVISION FACILITY EVALUATION REPORT (Cont) cho Regional ensue. 1on3 CORPORATE on #190 MONTERY PARK. CA 91754 FACILITY NAME: COURT YARD ESTATES FACILITY NUMBER: 198205250 VISIT DATE: 02I20i2019 NARRATIVE 8.Right upper posterior chest Stage 2- partial thickness skin loss, healing and aimost dry, no discharge, periwound intact. 9.Right mediai malleolus Stage 10.Right lateral Stage 1. On February 22, 2018, R1 was discharged back to Court Yard Estates on hospice care with diagnoses of Encephalopathy, suspect toxic metabolic etiology secondary to sepsis; sepsis, leukocytosis (per the Mayo Clinic high white blood), fever, suspect secondary to ieft lower lobe 10 pneumonia, with multiple pressure injuries; anemia, no signs and of bleeding; dementia; 11 functional paraplegia; upper and lower extremity contractions; and multiple pressure injuries. 13 During the investigation, the Department interviewed Staff1 who stated that on March 7,2018, he, observed that Rt was missing skin tissue on her left hand and what appeared to be bite marks on 16 the arch of her left foot as well as on the pressure injury at the base__of the big toe. Staff 1 observed 17 a rat and rat droppings around R?i?s bianket. 13 The licensee admitted that rats were observed inside the facility. but stated that he had recti?ed the 19 problem. 21 On March 11, 2018 R1 passed, away, and the death certificate listed the cause of death as sepsis 22 and pnebmonia. Based on a thorough investigation, which includes observation, interviews, and record reviews, the 26 Licensee failed to provide proper care and supervision to R1. This resulted in R1 suffering a serious 27 bodily injury, including the develbpment of numerous pressure injuries between August 2017 and 28 February 2018 and sdstaining rat bites to Ri?s body,.uitimately ieading to hospitailza?tion. 30 31 32 .. NAME: Myriam Luga TELEPHONE: (323) 980-4932 LICENSING EVALUATOR NAME: Cheraki Davis TELEPHONE: (323) 980-4935 Licensme EVALUATOR SIGNATURE: . DATE: 0212012019 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02I2012019 Llcaos (PAS) {03:04} Page: 1 of 1