Fullerton Villa

Allegation investigated: Staff do not allow residents to make decisions regarding their care Staff obtained hospice services on behalf of residents who do not meet the criteria for hospice care

Licensing Program Analyst (LPA) Jason Lund delivered complaint findings via email to Administrator Jae Wan RIm for the following allegations. Staff do not allow residents to make decisions regarding their care- LPA Lund reviewed interviews from Licensing Program Analyst (LPA) Lydia Martinez from 11/15/2024 from residents in care waiting to go to day program. Residents interviewed stated that they like to go to the day program. Administrator Jae Wan Rim stated that residents are not forced to go to day program and can go if they want or not. If residents want to go, they wait for the bus to take them to the program. Based on interviews with staff and residents in care LPA Lund could not verify the allegation. Unsubstantiated Based on interviews with staff and residents in care on the information provided, it was unclear if staff do not allow residents to make decisions regarding their care, therefore the allegation was deemed UNSUBSTANTIATED. Staff obtained hospice services on behalf of residents who do not meet the criteria for hospice care- LPA Lund interviewed Administrator Jae Wan Rim who stated that the facility Licensee doesn’t own a Hospice agency. The facility doesn’t obtain hospice services on behalf on the residents in care only residents doctors can obtain hospice for residents in care. Based on interview with Administrator Jae Wan Rim LPA Lund could not verify the allegation. Based on interview with Administrator Jae Wan Rim on the information provided, it was unclear if staff obtained hospice services on behalf of residents who do not meet the criteria for hospice care, therefore the allegation was deemed UNSUBSTANTIATED. As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is no preponderance of the evidence to prove that the alleged violation occurred. Report emailed to the facility.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 22-AS-20241105125047

Type of visit: Case Management - Incident

On May 29, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Incident inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Jae Wan Rim was present and assisted on today's inspection. LPA is following up on a self reported Unusual Incident/Injury Report received by the Orange County Regional Office on May 27, 2026, for Resident #1 (R1). The Unusual Incident/Injury Report stated that the facility was notified by R1's wound care specialist that his heel wound is currently unstageable. On today's visit, LPA, accompanied by the AD, conducted a tour of the facility. No health or safety concerns were observed. LPA also collected pertinent records for R1 including R1's Identification sheet, Medical Assessment, Pre-Admission Appraisal, Needs and Services Plans, Hospital Discharge documents, and Home Health Records. Due to insufficient information available at this time, this incident requires further investigation. No deficiencies are being cited per Title 22 of the California Code of Regulation on today's visit. An exit interview was conducted with Administrator Jae Wan Rim and a copy of the report was provided at time of visit.the state’s words, verbatim · CDSS document, May 29, 2026

Allegation investigated: Staff administered medication to a resident without proper consent

On February 18, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegation listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Jae Wan Rim was present and assisted on today's visit. During the course of the investigation, LPA conducted one staff interview, reviewed and obtained pertinent documents to the complaint. Regarding the allegation, staff administered medication to a resident without proper consent, the following has been concluded: It was alleged that staff administered medication to Resident #1 (R1) without proper consent. LPA reviewed R1's file including the admission agreement, medical assessment, pre-placement appraisal, resident appraisal, needs and services plan, and medication administration records. LPA observed there was no medical power of attorney on file for R1, or any other document in which the facility was required to obtain consent from R1's responsible party prior to administrating medication to R1. CONTINUED ON LIC9099-C Unfounded LPA observed that the facility was administering medication to R1 in accordance with her prescribed medication orders, as per regulations. There is also no regulations that requires the facility to obtain consent from a resident's responsible party prior to administering their prescribed medications. LPA conducted one staff interview. The staff interviewed confirmed that R1 did not have a medical power of attorney and that medications were administered in accordance to R1's prescribed orders. Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. An exit interview was conducted Administrator Jae Wan Rim and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 22-AS-20260213155556

Allegation investigated: Lack of care and supervision resulted in resident's decline. Facility did not notify responsible party of resident's change in condition. Facility denied the resident's right to reject medical care or other services. Facility did not ensure resident was provided 3 meals a day. Facility failed to provide basic hygiene items for resident.

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. An initial investigation visit was conducted on July 11, 2023 by the Department. It was alleged staff lack of care and supervision resulted in resident’s decline, facility did not notify responsible party of resident’s change in condition, facility denied the resident’s right to reject medical care or other services, facility did not ensure resident was provided 3 meals a day, and facility failed to provide basic hygiene items for resident. During the investigation, the Department conducted interviews with residents in care and staff. LPA Arias reviewed records obtained. The investigation determined as follows: Regarding the allegation lack of care and supervision resulted in resident’s decline, it was reported resident 1 (R1)’s ability to express themselves verbally deteriorated as a result of neglect. Continued on LIC9099-C dated 12/12/2025 Unfounded Record review revealed R1 was admitted to the facility on June 22, 2022. On June 23, 2022, R1 was admitted to hospice care due to a terminal diagnosis of cerebral infarction. Secondary diagnoses included dementia. Visits by a hospice nurse were conducted on June 23, 2022, June 28, 2022, and July 5, 2022. On July 5, 2022, R1’s family revoked hospice services and discharged R1 from the facility. LPA interviews with seven out of seven residents state their needs are being met by staff including meals, medication management, incontinence care, and general housekeeping. LPA interviews with four out of four staff stated they assist residents with activities of daily living including showers, assistance with transfers, escorting residents to the dining area, feeding, and incontinence care. Regarding the allegation facility did not notify responsible party of resident’s change in condition, it was reported R1 lost 14 pounds during R1’s stay at the facility from June 22, 2022 to July 5, 2022 and the responsible party was not informed. Record review revealed R1 was placed in a skilled nursing facility (SNF) from April 1, 2022 through June 22, 2022 due to a diagnosis of cerebral infarction. The SNF documented R1’s weight record on April 2, 2022 at 94lbs, April 4, 2022 at 93lbs, April 12, 2022 at 93lbs, April 17, 2022 at 92lbs, May 7, 2022 at 91lbs, May 23, 2022 at 91lbs, May 29, 2022 at 89lbs, June 5,2022 at 89lbs, June 8, 2022 at 89lbs, and June 12, 2022 at 87lbs. SNF assessments for R1 completed on April 1, 2022, April 8, 2022, April 15, 2022 and April 22, 2022 state “Rarely eats a complete meal and generally eats only about ½ of any food offered.” Hospital records for R1’s admission on July 6, 2022 document R1’s estimated weight at 80lbs. On July 8, 2022, actual weight was documented at 85lbs 15.7oz. R1’s hospital records from July 6, 2022 to July 10, 2022 indicated 25% to 71% of their meals were consumed. R1 was placed on a mechanical soft diet during the hospital stay. Regarding the allegation the facility denied the resident's right to reject medical care or other services, it was reported the facility had R1’s family sign documents to place R1 into hospice care without understanding the purpose of hospice care. Record review revealed R1’s responsible party signed documents agreeing to place R1 into hospice care on June 23, 2022 with the hospice agency. Included in the signed documents is a patient acknowledgement form outlining the overall purpose of hospice care. R1 was in hospice care from June 23, 2022 to July 5, 2022. R1’s responsible party signed a document revoking hospice care on July 5, 2022. Continued on LIC9099-C dated 12/12/2025 Regarding the allegation facility did not provide resident 3 meals a day, it was reported that R1 was fed porridge and was not being fed enough. LPA interviews with seven out of seven residents stated their needs are being met by the staff and get three meals per day. One out of seven residents added they need help with feeding and a staff member helps them with that. LPA interviews with two out of four staff stated part of their responsibilities is to feed residents who cannot feed themselves. One out of the remaining two staff stated they help bring food to residents’ rooms as needed. The remaining staff stated if they notice a resident not eating or eating enough, they will report it to the on-duty nurse. Record review revealed R1’s physician’s report dated June 23, 2022 stated that R1 be placed on a pureed diet. Regarding the allegation facility failed to provide basic hygiene items for resident, it was reported R1 did not have a toothbrush. LPA interviews with three out of four staff stated they assist residents in brushing their teeth. The remaining staff did not add anything relevant to this allegation. LPA observed signage in multiple rooms indicating which residents required assistance with brushing teeth. LPA observed cups with toothbrushes openly visible in some of the residents’ rooms. LPA along with Administrator (AD) Jae Wan Rim observed the storage room full of hygiene products for resident use including toothbrushes, toothpaste, and shampoo. AD stated every resident gets a toothbrush, toothpaste, and shampoo when they move in and will provide additional supplies when needed. Based on interviews, observations, and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted and a copy of the report was left with the facility representative.the state’s words, verbatim · CDSS document, Dec 12, 2025 · control 22-AS-20230711165849

Type of visit: Case Management - Incident

On November 20, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct a Case Management - Incident inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Jae Wan Rim was present and assisted on today's inspection. LPA is following up on a self-reported Death Report received by the Orange County Regional Office on November 20, 2025, for Resident #1 (R1). On today's visit, LPA, accompanied by the AD, inspected the facility. LPA observed the facility to be clear of any hazards. No health or safety concerns were observed. LPA collected pertinent records for R1 including R1's Identification sheet, Physician Reports, Pre-Admission Appraisal, and Needs and Services Plans. Due to insufficient information available at this time, this incident requires further investigation. No deficiencies are being cited per Title 22 of the California Code of Regulation on today's visit. An exit interview was conducted with Administrator Jae Wan Rim and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 20, 2025

Allegation investigated: Facility failed to issue a refund after a resident moved out Facility staff failed to provide a healthful environment, resulting in a resident's hospitalization

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. An initial investigation visit was conducted on February 15, 2024 by the Department. It was alleged staff facility failed to issue a refund after a resident moved out and facility staff failed to provide a healthful environment, resulting in a resident's hospitalization. During the investigation, the Department conducted interviews with residents in care and staff. LPA Arias reviewed records obtained. The investigation determined as follows: Regarding the allegation facility failed to issue a refund after a resident moved out, it was reported the facility did not provide a refund when resident 1 (R1) did not return to the facility after being hospitalized on January 3, 2024. Continued on LIC9099-C dated 10/23/2025 Unfounded R1's rent was prepaid for the month of January 2024. Per R1's admission agreement signed by R1's responsible person, page 5 states "There will be no refund of any portion of prepaid rent, except in the event of death of the resident..." In addition, page 7 states "The Resident agrees to give the Facility thirty(30) day written notice of the intent to move from the Facility." R1's responsible party notified the facility in writing on January 8, 2024 that R1 would not be returning to the facility and thus not providing a 30 day notice. Regarding the allegation facility staff failed to provide a healthful environment, resulting in a resident's hospitalization, it was reported the facility is dirty and there is a lack of hygiene. LPA toured the facility grounds including 6 resident rooms, dining areas on both levels, and kitchen. LPA observed the facility to be clean and in good repair. LPA observed the front lobby being mopped during the visit. LPA interviews with seven out of seven residents stated their rooms are cleaned every day. Two out of seven residents added their rooms are deep cleaned once or twice per week. Seven out of seven residents stated their needs are met by staff. LPA interviews with five out of five staff stated resident needs are being met. Four out of five staff added they assist the residents with taking out the trash daily from their rooms. Two out of five staff added they help with cleaning up the dining room after each service. LPA reviewed deep cleaning schedule from December 4,2023 through December 29, 2023 revealing an average of eight rooms being deep cleaned per day. Based on Department interviews, record review, and observations, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Exit interview was conducted and a copy of this report was left at the facility. The schedules revealed an average of ten care giving staff working the day shift, eight care giving staff working the evening shift, and three staff working the NOC shift. In addition, there were two med techs, two nursing staff, and five additional care givers working with higher need residents listed throughout the day and evening shifts. LPA pressed a call button while in a resident room and received an immediate response through the speaker. LPA interviews with six out of seven residents stated staff responds immediately when the call button is pressed. The remaining resident stated there have been a few instances in the early hours of the morning when they have pressed the call button with no response. LPA interviews with five out of five staff stated when a resident presses the call button, the front office is notified and staff is called to check on the resident using a walkie-talkie. Based on Department interviews, record review, and observations, the allegation is therefore deemed unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 22-AS-20240207092654

Allegation investigated: Staff not responding to resident's calls Staff not providing assistance to resident when brushing teeth

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation to the above identified complaint allegations. LPA arrived at the facility and was greeted and granted entry. LPA spoke with Jae Wan Rim, Administrator and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, and interviews conducted. It is alleged that staff not responding to residents’ calls. Interviews with 10 of 10 residents stated that when they call for help, they have always gotten the help they need, and staff come to help them all the time. They stated that they have waited about 10-15 minutes at a time, but they have not waited too long. Interview with staff stated that they get the call and the caregiver that is assigned to that area of the facility Continued on LIC9099-C Unsubstantiated answers the call. LPA Lydia Martinez conducted a tour of the facility on July 19, 2022, and observed caregivers on the floor getting calls for assistance and answering those call and assisting residents. It is alleged that staff not providing assistance to residents when brushing teeth. Interview with 3 of 3 staff stated that they help resident (R1) with their brushing needs. Teeth were brushed after every meal or at a minimum 3 times a day. Staff stated that when they would brush R1’s teeth that they never observed any blood coming from their gums. R1 would get combative at time and staff would assist in calming them down and try to brush their teeth again. They would not force R1 to brush their teeth because they know resident have rights to refuse. Interview with 10 of 10 residents stated that they have observed staff helping other residents when they need help. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the Administrator and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 22-AS-20220712101114

Type of visit: Case Management - Incident

On September 12, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced Case Management visit to the facility. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Jae Wan Rim was present and assisted on today's inspection. LPA is following up on a self reported Unusual Incident/Injury Report (UIIR) that was received by the Orange County Regional Office (OCRO) on September 2, 2025. The UIIR described that on August 31, 2025, Resident #1 (R1) had an unwitnessed fall in her bedroom which resulted in her hospitalization. On today's visit, LPA and the AD conducted a tour of the facility, including R1's bedroom. LPA reviewed and obtained pertinent documents for R1 as well as conducted one staff interview. Based on the information gathered during the inspection, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Jae Wan Rim and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 12, 2025

Type of visit: Required - 1 Year

On August 29, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Administrator (AD) Jae Wan Rim was present and assisted LPA on today's inspection. LPA observed that Jae Wan Rim has a valid Administrator certificate which expires on May 15, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for one hundred and ninety seven residents and has a hospice waiver for twenty five. The facility is a two story building. The first floor consist of a lobby, five staff offices, an activity room, a lounge, a laundry room, a commercial kitchen, a dining room, a maintenance room, resident bedrooms, with bathrooms located in suite, and an outdoor courtyard area. The second story consist of a lounge, a dining room, resident bedrooms, with bathrooms located in suite, and a outdoor patio area. On today's visit, there are one hundred and fifty two resident in care. LPA observed the See Something, Say Something poster, (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected ten resident bedrooms on the first and second floor and observed them to be free of hazards. LPA observed resident bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed additional linens to be stored in the laundry room. LPA additionally tested the alarm systems in the resident bedrooms which tested operational. LPA inspected the resident bathrooms in each of the resident bedrooms and observed them to be clean. Bathrooms were equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 106.8 and 116 degrees Fahrenheit. LPA observed the commercial kitchen to be kept off limits to residents in care. LPA observed the kitchen has a two day perishable and a seven day non-perishable food supply on hand. CONTINUED ON LIC809-C LPA observed kitchen appliances to be clean and operational. LPA observed knives and sharps to be stored in the kitchen. LPA observed fire extinguishers to be mounted on the walls throughout the first and second floor of the facility. LPA observed fire extinguishers to be charged and serviced as of December 19, 2024. LPA observed the facility passed their most recent fire inspection conducted on August 19, 2025. The fire inspection consisted of testing the facility smoke detectors, carbon monoxide detectors, and fire sprinklers, all of which tested operational. LPA observed the facility conducted their last emergency disaster drill on July 28, 2025. LPA observed the centrally stored medication to be kept in a locked cabinets located in the nurse's office located on the first floor. LPA also observed the facility has a First Aid Kit stored in the nurse's office and it has all the required components. LPA observed all facility common areas such as the lounges on the first and second floor, the dining rooms of the first and second floor, the activity rooms on the first and second floor, to be clear of any obstructions or hazards. LPA inspected all facility staircases and observed them to be clear of hazards. LPA also observed each staircase to have an emergency evacuation chair. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA observed all facility chemicals and toxins to be kept locked in the maintenance room. LPA, accompanied by the AD, conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of hazards and obstructions. LPA observed a shaded outdoor seating area with furniture for resident use. There are no bodies of water on the premises. LPA reviewed fifteen resident files. All the required documentation were present and current in the resident file reviewed. LPA reviewed the residents' medication and medication records. LPA reviewed eight staff files. All staff are background cleared and associated to the facility. Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Jae Wan Rim and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 29, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year inspection. LPA met with Administrator Jae Wan Rim. LPA confirmed Administrator has a current Administrator Certificate which expires on 05/15/2026 The facility is operating within capacity limitations. Facility currently has 167 residents in care of which six residents are under Hospice care. Community is mostly Korean speaking residents. LPA observed residents walking around socializing, or relaxing in their respective rooms. In-House Doctor was present seeing residents during today's visit. Residents were observed clean, content and well taken care of. LPA observed the facility to be clean and in good repair. LPA observed new flooring on first floor is being installed. Facility provided notice to CCL prior to start of installation. The facility is maintained at a comfortable temperature. Lighting is sufficient for safety and comfort. Patio has a covered area with seating for residents and visitors. Hygiene items were observed to be readily available for residents in care. Hot water was found to be within regulatory requirements. Grab bars were found available in restrooms used by residents. As this is a multi-level licensed structure, a signal system was found in place, tested and functional. Annual Fire Inspection reports and Fire Prevention Services documentation was available for review. Records of Maintenance and Emergency Drills were available for review, last being 07/04/2024. Sprinkler system was inspected and documentation was reviewed. LPA, along with AD Rim toured and inspected the kitchen, reviewed lunch service and reviewed monthly dietician's inspection reports. Last dietician's report and sanitation survey form was dated 09/06/2024. Dietician provided in-service training in area of menu availability for Korean residents was observed. LPA observed menu posted in English and Korean. LPA observed a one week supply of nonperishable foods and two days of perishable foods. Pesticides and other toxins are stored away from food areas of the kitchen. Sharp items are also kept inaccessible from residents. LPA also observed adequate Care and Supervision for the number of residents in care. (cont...LIC809C) Medications are centrally stored and inaccessible to residents in care. LPA observed medication is pre-poured for 3 days. LPA observed resident centered activities posted. LPA conducted interviews with residents and staff. LPA reviewed 16 resident files and 5 staff files Based on observations made during today's visit, deficiency is being cited per Title 22. An exit interview was conducted with Administrator and a copy of this report (LIC809, LIC809D and Appeals Right) was sent to email on file.the state’s words, verbatim · CDSS document, Sep 20, 2024

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Lydia Martinez conducted this Case Management evaluation, in conjunction with a complaint visit Control Number 22-AS-20240819160531. The purpose of this visit was to conduct a Health and Safety evaluation. LPA, along with AD Rim and AD Lindley toured the facility. LPA observed Residents in care appeared to be safe no imminent health and safety hazards were observed. LPA observed residents in their respective rooms and in the activity room playing Bingo others were roaming around the facility. LPA observed residents to be well groomed and no visible injuries noted. Rooms were observed clean and free of foul odor. Food supply was observed to be adequate during this inspection. Facility was maintained at a comfortable temperature for the residents in care. There were no deficiencies issued during this Case Management visit. LIC9102 Advisory Note was issued. An exit interview was conducted with AD Rim and AD Lindley and a copy of this report was sent to email on file.the state’s words, verbatim · CDSS document, Aug 21, 2024

Type of visit: Case Management - Other

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to conduct 10 day visit for complaint control #22-AS-20240207092654. LPA Quiroz met with Assistant Administrator Jae-Wan Rim and discussed purpose of today's visit. On or about 12:05pm, while conducting facility inspection visit on first floor in Activity room, LPA Quiroz observed open ceiling with trash bin observed to be placed due to leaking ceiling. This was verified with Assistant Administrator Jae-Wan Rim who indicated "Yesterday, we thought it was a fire sprinkler drip so we called our fire consultants who then opened the ceiling and ruled out fire sprinkler issue and said it was a plumbing issue, but they had to open up the ceiling to inspect it and now our maintenance director is working on it." LPA Quiroz provided consultation on CCR 87211: Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. Administrator Assistant Rim indicated understanding CCR 87211: Reporting Requirements indicating he informed CCL during today's visit and will follow up with assigned LPA during process and repair of ceiling in Activity room on 1st floor. Technical assistance provided during today's visit. (See LIC 9102-TA) An exit interview was conducted, and a copy of this report, LIC 9102-TA were provided at exit.the state’s words, verbatim · CDSS document, Feb 15, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management inspection to follow-up on an incident report received by Community Care Licensing on 2/05/2024. LPA met with Assistant Administrator (AAD) Jae Win Rim and explained the reason for the visit. Incident report indicated that on 2/03/2024 at about 4:00 p.m., direct care staff informed front desk that Resident 1 (R1) was not in the dining area. Staff initiated search for R1. Camera footage was reviewed, and resident was seen leaving the facility at 3:22 p.m. Police were called and R1’s family was notified. Facility staff continued to try to locate R1 and found them at the nearest 4-way intersection. During today’s visit, LPA interviewed AAD who confirmed details of the incident report. LPA was unable to interview R1, as they away at day program. LPA reviewed R1’s Physician Report (LIC602) dated 7/05/23, which indicates R1 has a dementia diagnosis and wandering behavior. LPA also reviewed Resident Appraisal (LIC603) dated 1/27/24, which indicates R1 needs special observation and 24-hour supervision. Based on information gathered, LPA determined that staff did not adequately supervise R1, resulting in elopement from the facility; a Deficiency was cited on today’s date. An exit interview conducted, and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Feb 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Feb 13, 2024

“Care and supervision” means the facility assumes responsibility for, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidence by: Based on information gathered, the facility did not assume responsibility for Resident’s wandering behavior, resulting in elopement from the facility, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 12, 2024

Plan of correction: AAD stated resident has been placed on a 1:1 ratio to ensure 24-hour supervision and training regarding resident elopement would be conducted. AAD stated they would provide LPA with proof of training via email by POC.

Allegation investigated: Facility is not following resident's admission agreement.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose to investigate into the above allegation. LPA met with Administrator (Admin) Darlene Lindley, explained the reason for the visit, and discussed the elements of the allegation. On December 4, 2020, the Department received the complaint, and the 10-day investigation was initiated by LPA Lydia Martinez. LPA Martinez conducted the investigation via telephone and obtained the records via email due to the Coronavirus 2019 precautionary measures at that point in time. During today's visit, LPA Jessica Cho obtained addtional resident records and interviewed resident/staff. The following was revealed during the course of the investigation pertaining to Resident #1 (R1): It is alleged that the facility is not following the resident's admission agreement. In review of the parking fee notice dated November 10, 2020, the notice indicates effective December 10, 2020, there would be a fee of $100.00 for residents utilizing the parking lot. Unfounded The parking fee however was waived as noted on the letter sent to R1 on December 10, 2020. In the statements from R1 and Staff #1 (S1), both confirmed that the parking fee was waived and the issue was resolved. It is determined that the facility adhered to the admission agreement by not imposing the parking fee. Therefore, this agency has investigated the complaint and based on the interviews which were conducted and the records that were reviewed, the following allegation: Facility is not following the resident's admission agreement is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Administrator Darlene Lindley, and a copy of this report and the LIC811s were provided at the end of the visit.the state’s words, verbatim · CDSS document, Dec 13, 2023 · control 22-AS-20201204161940

Allegation investigated: Facility did not prevent the spread of scabies

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to investigate the complaint allegation above. LPA Haley identified himself and explained the reason for the visit with staff. During the visit, staff lead a brief tour of the facility before interviews began. Regarding the allegation: Facility did not prevent the spread of scabies During the investigation, interviews were conducted with Administrator Darlene Lindley, staff members and residents. 5 individuals interviewed confirmed residents had scabies. 4 staff members interviewed confirmed residents had scabies in 2020. Staff 1 (S1) stated the scabies were treated right away. S1 claimed the facilities in house doctor prescribed cream to treat the residents who had scabies and their roommate, even if the roommate did not have scabies they were still treated. Staff 2 (S2) confirmed residents had scabies and said residents were treated with cream, isolated, rooms were sanitized, and cloths were separated and cleaned. Continued on LIC9099C Unsubstantiated Staff 3 (S3) confirmed the outbreak and said it lasted about two or three weeks. During interviews with S3 and S4, they both said they were pleased with how the facility handled the scabies outbreak. S3 said, “Once they found out, they immediately sanitized the room, separated the residents, and they didn’t allow contact with other residents.” Residents 1 (R1) confirmed they had scabies. R1 claims they were itching really bad and said it was unbearable. R1 claims a former manger at the facility helped the resident get better. Other residents interviewed said they did not have scabies, and both claimed they were not aware anyone had scabies during that time. Based on the evidence gathered through interviews, and document review, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 22-AS-20200814090028

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jerome Haley conducted a case management visit regarding information discovered during the investigation into complaint control # 22-AS-20200814090028. During the complaint investigation mentioned above, it was discovered the facility had an outbreak of scabies in 2020. During interviews, 4 staff members and 1 resident confirmed the scabies outbreak. According to the staff members the outbreak lasted about two/three weeks. Resident’s who had scabies were treated with a cream, isolated, rooms were sanitized, and clothing was washed separately. After reviewing incident reports submitted to the Orange County Adult and Senior Care Program Regional Office, it was discovered the scabies outbreak in 2020 was not reported to the Department as required. As a result of today’s Case Management visit, deficiencies will be cited. An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 12, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Dec 19, 2023

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (2) Occurrences, such as epidemic outbreaks,...or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours... to the licensing agency and to the local health officer when appropriate. This requirement is not being met as evidenced by the outbreak of scabies in 2020. The outbreak was confirmed by staff and a resident. After reviewing incident reports submitted to the Regional Office it was discovered the scabies outbreak was not reported as required.the state’s words, verbatim · CDSS document, Dec 12, 2023

Plan of correction: Administrator Lindley will review Regulation Section 87211 and email a statement of understanding and a plan of action that will prevent a failure to report in the future. Administrator Lindley will include who will be responsible for submitting incident reports and who will be the back up incase the designated personable is not available. The POC is due no later than Tuesday, December 19, 2023 at 1:00PM.

Allegation investigated: Resident sustained injuries from a fall while in care Staff is threatening resident with eviction

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility for the complaint received on 10/06/2020 and to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by facility administrator (AD) Darlene Lindley and Assistant Administrator Jae Rim. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that resident sustained injuries from a fall while in care. Per resident (R1) physician report, R1 is non-ambulatory and has a history of falling and wandering. R1 was also reported to have dementia with behavioral disturbances. On 9/29/2020 and 10/02/2020, the facility observed that R1 had redness around the eyes, to which the facility contacted medical care and R1 was sent to the hospital to obtain further evaluation and treatment, and reported the incidents to R1's family on the same day. Unsubstantiated R1 was placed on hospice on 10/01/2020 by R1’s responsible party and requested for 24 hour supervision to be conducted from the hospice agency. It was alleged that the staff is threatening resident with eviction. Per interview with facility staff, it was revealed that facility staff will remind residents about the option of moving out of the facility if a resident is unhappy residing at the facility, however, per documentation review, there were no records of the facility issuing R1 with an eviction, or any documented warnings to R1 about an eviction. Following R1’s hospitalization on 10/02/2020, the facility followed up with R1’s responsible party to inquire about a return date, to which R1’s responsible party had stated that R1’s doctor suggested for R1 to live elsewhere to obtain a higher level of care, to which the family agreed, therefore, R1 did not return to the facility. Facility issued R1’s responsible party a refund and removed R1’s belongings out of the facility on 10/18/2020. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegations occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Assistant Administrator Rim. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Dec 11, 2023 · control 22-AS-20201006152005

Allegation investigated: Staff not giving resident PRN medication.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to continue the investigation into the allegation listed above. LPA met with Administrator Darlene Lindley. LPA explained the reason for the visit. LPA reviewed facility records for Resident 1 (R1). LPA and Administrator toured the facility. The investigation revealed the following. Facility records for R1 show R1 was prescribed Hydrocodone-Acetamin 5-325 MG as needed (for pain) and Lorazepam .5 MG as needed (PRN medications). It was reported that on 9/22/2020 the facility did not provide R1 with their PRN Hydrocodone-Acetamin when requested by R1. Facility records show that R1's health care provider sent the facility orders on 9/22/2020 and 9/24/2020 to hold their PRN Hydrocodone-Acetamin till further orders are provided. The Administrator reported that R1 was made aware of the orders by their healthcare provider and by facility staff. R1 no longer resides at the facility and their where abouts are unknown. There is no current contact information for R1. R1 could not be reached for interview. Based on the evidence gathered the allegation is deemed unfounded, meaning the allegation is false could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided. Unfoundedthe state’s words, verbatim · CDSS document, Dec 11, 2023 · control 22-AS-20200923110812

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained fracture due to staff neglect. Staff are not meeting resident's laundry needs. Staff did not safeguard resident's clothing. Staff did not feed resident. Staff did not properly dress resident.

.Licensing Program Analyst (LPA) Jessica Cho arrived unannounced and met with Adminstrator Darlene Lindley for the purpose of delivering the findings into the above allegations. On June 28, 2023, the Department received the complaint, and the investigation was initiated by LPA Kimberly Lyman on June 29, 2023. During the visit on June 29th, LPA Lyman obtained records and conducted the health and safety inspection, and there were no identified concerns observed at the time of the visit. On September 8, 2023, LPA Jessica Cho continued the complaint investigation, interviewed residents and staff, and obtained additional facility and resident records. Interviews were further conducted by LPA Cho via phone calls on September 27, 2023. The following are the findings investigated by the Department which involved a review of records and interviews pertaining to Resident #1 (R1): Unsubstantiated It is alleged that the resident sustained a fracture due to staff neglect. R1 is diagnosed with Dementia as noted in the Physician’s Report dated April 19, 2023. On May 28, 2023, R1 sustained a fall per the Unusual Incident/Injury Report (UR). The investigation revealed that three out of the three staff confirmed during the interviews that R1 was able to walk without any physical assistance (e.g., walker, cane, or other person) however had unsteady gait prior to the fall. R1 received physical therapy to increase mobility and improve their gait as noted on the home health Progress Notes dated May 27, 2023. The Department reviewed the surveillance footage for May 28, 2023, capturing R1 falling face-down in an attempt to reach for the roommate’s left hand; and as a result, struck their right shoulder against the floor of the hallway. Based on interviews which were conducted, review of documents obtained, and observations, it is determined that there was insufficient evidence to corroborate R1 sustaining a fracture due to staff neglect as R1 was not evaluated as a fall risk. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed unsubstantiated. It is alleged that the staff are not meeting the resident’s laundry needs. In review of the staff’s personal laundry notes from January 2, 2023 to September 7, 2023, R1’s clothes were washed every Wednesdays. During those months, the staff was absent for three days: April 12, June 15, and June 16, 2023. Out of the three days, April 12th fell on a Wednesday which was the designated laundry day for R1. Staff stated that R1’s clothes were not washed on April 12th, however, were washed within the week. Per LPA’s review, staff could not recall nor has documented the day R1’s clothes were washed following their absence. Interviews conducted with a total of seven staff indicated that the resident’s clothing appeared clean. Five out of the seven staff confirmed that the dirty laundry was washed weekly while two out of the seven staff were unaware of the laundry schedule. Three out of the six residents expressed contentment with their weekly laundry service while two out of the six residents could not be interviewed as the residents exhibited cognitive impairments and disorientation. One remaining resident indicated that they did not opt to pay additional fees for the laundry service. Although the laundry notes for the week of April 12, 2023, did not document R1’s clothes were washed, the interviews reveal that R1’s clothing was observed to be clean in appearance. Therefore, the evidence obtained did not support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed unsubstantiated. It is alleged that the staff did not safeguard the resident’s clothing. Per review of R1’s Clothing and Possessions form dated February 2, 2021, there were no missing items that were reported. Two out of the two residents could not be interviewed as both are disoriented. Seven out of the seven staff stated that they did not have knowledge of R1 missing their clothing items, therefore the evidence collected did not support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed unsubstantiated. It is alleged that the staff did not feed the resident. After R1’s fall on May 28, 2023, R1 sustained a surgical neck fracture to the right arm as noted on the X-Ray report dated May 31, 2023. As a result, R1 was unable to feed themself due to pain. Two out of the two residents could not be interviewed as both residents were cognitively impaired and disoriented. Five out of the five staff stated that R1 was fed every meal after the fall and was provided Ensure when food was refused. In addition, when R1 was hospitalized from the fall at the initial hospital, the patient progress notes dated May 28, 2023 documented R1’s height at 5’2” and R1’s weight to be at 120 lbs. The discharge summary notes from the final hospital documented R1’s weight to be 110 lbs with a total weight loss of 10lbs. The evidence obtained from the interviews and the medical records did not support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed unsubstantiated. It is alleged that staff did not properly dress the resident. LPA was unable to interview R1 as R1 was not alert and oriented. Interviews conducted with five staff indicated that R1 was properly dressed and wore their own clothes during their stay at the facility. One staff who was present on June 9, 2023, when R1 was hospitalized, observed R1 being transported to the hospital with a blanket covering their exposed lower half of the body due to R1 refusing to wear their pants. The evidence obtained during the investigation did not support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Administrator Darlene Lindley, and a copy of this report including the LIC9099-Cs, and the LIC811 were provided at the end of the visit. It is alleged that the staff did not notify the resident’s authorized representative of the fracture in a timely manner. In review of the records obtained, the following is a chronological timeline of events beginning from the date of the fall: On May 28, 2023, R1 sustained a fall as noted on the Unusual Incident/Injury Report (UR). R1 was admitted to the hospital and returned to the community the same day. The medical records dated May 28, 2023, reveal that R1 did not sustain a fracture/dislocation however presented calcific rotator cuff tendinitis, moderate acromioclavicular joint space arthrosis, and mild glenohumeral degenerative change with acute Urinary Tract Infection (UTI). R1 was prescribed medications to treat the UTI and alleviate shoulder pain. On May 29, 2023, staff observed R1 in pain and requested an X-ray of R1’s primary care physician (PCP) as documented on the M.D. Order. In response, the PCP authorized an X-Ray of the right arm, shoulder, and hip which the order was received by the facility on May 31, 2023, at 10:12am. On May 31, 2023, at 3:25pm, the X-Ray revealed R1 sustaining a surgical neck fracture to the right arm. The X-Ray finding was received by the facility the same day at 9:43pm. The administrator admitted locating the X-ray results on June 9, 2023, which was nine days after receiving the results. Therefore, R1’s authorized representatives were notified nine days after the x-ray results were received. It is determined that the above allegation occurred as reported, therefore, the allegation is substantiated, meaning that the preponderance of evidence standard has been met. It is alleged that the staff did not seek medical attention for the resident. The surveillance footage of the fall on May 28, 2023, obtained by the Department reveals that an unknown staff responded to the incident within approximately ten seconds and a supervisor arrived within approximately one minute. 911 was called and the Fullerton Fire Department arrived at the scene within eighteen minutes. Although the response to the incident was timely, the handling of the X-Ray result of a fracture was not timely. The result of the X-ray indicating a right humeral head/surgical neck fracture was faxed to the facility on May 31, 2023, at 10:12am. Per interview with Staff #1 (S1), S1 stated that she is responsible to process medical records however was reassigned with a different duty and did not see the X-Ray results come through for R1. S1 indicated that she saw the X-Ray results while reviewing R1’s file and subsequently transferred R1 to the hospital for evaluation on June 9, 2023. Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation Staff did not seek medical attention for resident is deemed SUBSTANTIATED per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. Two deficiencies are being cited on the following LIC9099-D. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49. An exit interview was conducted with Administrator Darlene Lindley, and a copy of this report including the LIC9099-Cs, LIC9099-D, LIC811, and the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Oct 18, 2023 · control 22-AS-20230628100247

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(1) · Plan of correction due date: Oct 25, 2023

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in…the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator… when a resident’s behavior or condition changes. This requirement was not met as evidenced by: Based on LPA’s interviews and record review, two out of two staff made an admission that the authorized representative was notified 9 days after receiving the x-ray result which poses a potential Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: The administrator stated they will train their staff and provide proof of training addressing cited regulation to LPA via email by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87446 · Plan of correction due date: Oct 19, 2023

87446 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…and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Based on LPA's interviews and record review, two out of the two staff confirmed not seeking medical attention in a timely manner due to discovering the x-ray results 9 days later which poses an immediate Health, Safety, and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: The administrator stated they will develop procedures to track medical orders and medical exam or test results and will train their staff. The proof of training addressing cited regulation will be provided to LPA via email by POC due date.