Garden Grove Guest Home

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: - Resident’s representative was not provided with a copy of the admission agreement - Facility staff did not communicate with the authorized representative - Facility staff did not ensure residents’ information was kept confidential

On this date, Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the purpose of the visit. Assistant Administrator (AA) Paige Rohrer arrived shortly to assist with the inspection. The Department received a complaint on May 18, 2026. During the investigation, LPA Tea conducted interviews with residents, witnesses, and facility staff, and reviewed and collected pertinent records and information. Regarding the allegation that the resident's representative was not provided with a copy of the admission agreement, interviews revealed that the responsible party received a copy of the admission agreement. (Complaint Investigation Report continued on LIC9099-C) Unsubstantiated Resident 1 (R1) confirmed that the family member received the agreement and later requested additional copies. Facility staff also stated that a copy was provided after the agreement was signed. AA Rohrer stated that after providing a signed copy of the admission agreement, she advises the responsible party to take the document to the Social Security Office to maximize the resident's benefits. Regarding the allegation that facility staff did not communicate with the authorized representative, AA Rohrer stated that she regularly communicated with the responsible party and provided records showing ongoing communication. Facility staff confirmed that calls and messages from the responsible party were returned. Staff further stated that the responsible party frequently contacted the facility when AA Rohrer was not present, but she routinely returned the calls and maintained communication. Regarding the allegation that facility staff did not ensure residents' information was kept confidential, a witness reported observing paperwork on a desk. However, AA Rohrer and facility staff stated that resident records were maintained inside the administrator's office and were accessible only to authorized personnel. Staff further stated that confidential documents did not leave the office and that the office door remained closed when not occupied by authorized staff. Based on interviews conducted and records reviewed, there was insufficient evidence to prove or disprove the allegations. Therefore, the allegations mentioned above are deemed UNSUBSTANTIATED, meaning that although the allegations may have occurred or may be valid, there is not a preponderance of evidence to prove that the alleged violations occurred. No deficiencies are being cited at this time. An exit interview was conducted with the facility, and a copy of this report and the Confidential Names List were provided.the state’s words, verbatim · CDSS document, Jun 11, 2026 · control 22-AS-20260518141019

Allegation investigated: Staff did not prevent a resident from developing a pressure injury. Staff did not administer medication to a resident in care.

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to investigate the above mentioned complaint allegation. LPA was greeted and granted entry by staff. LPA met with Assistant Administrator (AA) Paige Rohrer and discussed the purpose of the visit. The investigation into the allegation of staff did not prevent a resident from developing a pressure injury revealed the following: Resident #1(R1) was admitted to the facility on March 20, 2022. LPA observed a physicians report for R1 dated March 20, 2022, stating that R1 had no history of a skin condition/breakdown and that they were able to communicate their needs. R1 was marked as ambulatory on the physicians report. LPA did not observe an updated physicians report for R1. LPA observed a functional capability assessment for R1 dated April 2, 2023, stating that R1 needed full assist with bathing, dressing, toileting, transferring, eating, grooming and repositioning. LPA observed that R1 was noted to be able to make their needs known. Continue on 9099C Unsubstantiated This assessment was signed by facility personnel only. LPA observed outside agency progress notes for R1 dated June 7, 2023 to July 24, 2023 from Kaiser home health personnel to provide stage 2 wound care on R1s coccyx . LPA observed home health personnel to notate the wound to be a stage 3 pressure wound on June 16, 2023 with notes of instruction to staff on ADLs with no other changes. LPA observed notations of no new wounds or significant changes for R1 throughout the home health personnel documents. LPA observed notations on July 7, 2023, noting instructions for facility staff and that the wound is improving. On July 12, 2023 home health personnel noted that R1 was improving with positive skin growth to the wound. LPA observed notations from home health personnel that R1s wound had healed and wound care was to be discontinued on July 24, 2023. LPA did not observe home health documents from April of 2023 due to the facility not having the documents. LPA interviewed staff regarding R1s pressure wound and three of five staff could not recall or did not know about R1s pressure wound. One of five staff remembered a home health agency coming to the facility for R1 but could not recall why. One of five staff informed LPA that they remembered R1 having bed sores but could not recall if R1 received home health services due to the pressure wound. The Department interviewed staff in September of 2023 that stated R1 received all their medications even if they had to dispense the medication themselves. LPA interviewed five staff regarding R1s medication administration and five of five staff could not recall or did not know about R1s medications. One of five staff informed LPA that they did not dispense medications to R1 due to not having to dispense any medications during the night shift. Two of five staff informed LPA that they do not dispense medications to residents in care. LPA observed current client medications and observed that they were being given as prescribed. LPA interviewed three of three residents in care and was informed that they receive all their medications as prescribed with no issues. LPA was unable to interview R1 due to not being at the facility anymore. Although it was alleged that staff did not prevent a resident from developing a pressure injury, LPA was unable to review all home health records due to the facility not retaining resident documentation from April of 2023 along with facility notes pertaining to needs and services provided by the facility and the progression of R1s wounds. This allegation has been deemed UNSUBSTANTIATED. Continue on LIC9099C Although it was alleged that staff did not administer medication to a resident in care LPA was unable to review R1s physicians orders or medication administration record due to the facility not retaining resident documentation. This allegation has been deemed UNSUBSTANTIATED. Based on information gathered, interviews and record review, the Department is unable to ascertain if the above 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 violations occurred: Therefore, the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 13, 2026 · control 22-AS-20230905130429

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct a case management visit. LPA was greeted and granted entry by staff. LPA met with Assistant Administrator (AA) Paige Rohrer and discussed the purpose of the visit. During the investigation of complaint 22-AS-20230905130429 Resident #1 (R1) file was given to LPA for review and it was incomplete. LPA did not observe medication records, physicians reports and needs and services plans for R1. Staff #1 (S1) informed LPA that they do not have all the documents of past residents due to the management at the time not storing files properly and not saving the documents for the regulatory amount of time. R1 was admitted to the facility on March 20, 2022, with the latest documentation of R1 still being at the facility on July 24, 2023. LPA was unable to confirm the exact date of R1 leaving the facility. Based on today’s observations a deficiency is being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this along with LIC 809D and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jan 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Feb 3, 2026

87506(e) Resident Records Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidence by: LPA observed the last documentation done for R1 in July 2023, but did not observe R1s completed file. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: Licensee stated that they will create a policy regarding the cited regulation and retaining documentation and conduct an in service with facility management and send proof to LPA by POC due date.

Allegation investigated: Resident sustained unexplained bruising while in care Staff did not seek timely medical attention for a resident

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to investigate the above mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with Assistant Administrator (AA) Paige Rohrer and discussed the purpose of the visit. The investigation into the facility allegations of resident sustained unexplained bruising while in care and staff did not seek timely medical attention for a resident revealed the following: Resident #1 (R1) was admitted to the facility October 18, 2023. LPA observed a physicians report dated October 18, 2023, stating that R1 had a diagnosis of dementia and had motor impairment with a note of using a roller walker. R1 did not have a history of a skin condition/breakdown. R1 was noted as non ambulatory due to their physical condition. LPA observed a needs and services plan dated October 18, 2023, stating that R1 was returning from a skilled nursing facility due to a fall. The needs and services plan noted that R1 had no physical disabilities and was able to walk safely with their walker and will be evaluated through reports if falls or injuries happen. Continue on LIC 9099C Unsubstantiated LPA did not observe any incident reports of progress notes for R1. The Department interviewed four staff in May of 2024 and it was revealed that four of four staff stated the bruising was noted between April 25, 2024, and April 28, 2024. R1 was sent to the hospital on April 28, 2024, due to the bruising around their eyes becoming darker. Four of four staff stated that R1 was not sent out when it was first noticed due to R1 refusing. R1 agreed to go to the hospital on April 28, 2024 due to the bruising around their eyes getting darker. During interviews with four of five staff informed LPA that they do not remember bruising on R1. Three of five staff informed LPA that they did not remember if R1 was sent to the hospital. One of five staff informed LPA that they remembered R1 going to the hospital but did not recall what for and when it was. One of five staff was not at the facility at the time of the incident. LPA observed updated staff training's on resident care and when to report to a medication technician on March 1, 2025. Although the above allegations may have happened there is not a preponderance of evidence to prove the alleged violations occurred; therefore, the allegations that resident sustained unexplained bruising while in care and staff did not seek timely medical attention for a resident are deemed UNSUBSTANTIATED. Therefore, the Department dismisses the allegations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 12, 2025 · control 22-AS-20240430125543

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a case management visit. LPA was greeted and granted entry by staff. LPA met with Assistant Administrator (AA) Paige Rohrer and discussed the purpose of the visit. During the complaint investigation 22-AS-20240430125543 LPA did not observe incident reports for Resident #1(R1) regarding an incident on April 25, 2024 that lead to a hospital visit on April 28, 2024. LPA did not observe an incident report in the Regional Office database or in R1s file. Based on today’s observations a deficiency is being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC 809D and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Dec 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 2, 2026

87211(a)(1) Reporting Requirements (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement was not met as evidence by: LPA did not observe an incident report for R1 for an incident that happned on April 25, 2024. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2025

Plan of correction: Licensee stated they will conduct an in service on reporting requirements to all staff and send proof to LPA by POC due date.

Allegation investigated: Staff did not ensure residents thermostat in room was working properly. Staff did not ensure residents room does not smell like urine. Staff did not ensure residents bathroom and floors are cleaned timely.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of continuing the investigation into the above allegations. LPA met with Assistant Administrator(AA)/Wellness Director (WD) Paige Rohrer and explained the reason for the visit. On April 13, 2023, the Department received the complaint which the investigation was initiated by LPA Jenifer Tirre on April 20, 2023. During the course of the investigation, LPA Tirre and/or Cho toured the faciltiy, conducted interviews with two staff and four residents, and obtained the following documentation: Resident/Staff Rosters, Housekeeping Schedule, Face Sheets, and Physician's Reports. The investigation is as follows: Regarding the allegation, Staff did not ensure resident's thermostat in room was working properly, it is alleged that the thermostat in the unit was broken for three months. LPA observed no thermostats in the the four resident units inspected also corroborated by two out of two staff. Unfounded LPA observed one thermostat in each hallway, and a comfortable temperature was maintained throughout the facility and in the four units, 78-80 degrees Fahrenheit. Regarding the allegation, Staff did not ensure residents' room does not smell like urine, there was no urine odor throughout the facility and shared bathrooms in four out of four units inspected. There was no urine on the floor and no odor in any bathrooms. Four out of four residents and two out of two staff denied the allegation indicating that bathrooms are cleaned daily and as needed. Regarding the allegation, Staff did not ensure resident bathrooms and floors are cleaned timely, LPA observed one housekeeper cleaning the facility during the visit. LPA observed the floors in the shared bathrooms in four of four units and two shared showers in the hallways were clean and sanitary. Therefore, this agency has investigated the complaint and based on the observations made, interviews which were conducted, and the records that were reviewed, all allegations are deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Assistant Administrator/Wellness Director Paige Rohrer, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Nov 3, 2025 · control 22-AS-20230413144738

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 47 non-ambulatory residents, with a hospice waiver for twenty-seven. Currently there are 36 residents, zero on hospice during today's visit. The Assistant Administrator (AA), Paige Rohrer arrived later to assist during the visit. LPA Tea reviewed seven resident files and three staff files. Resident files and staff files contained most of the required documentation. Just a minor issue, some resident files were missing Personal Rights and Medical Emergency consent forms. Upon review of records, the facility is up to date with the required quarterly emergency disaster drill, which was last conducted on August 25, 2025. The administrator’s certificate expires February 20, 2027. LPA Tea along with AA Rohrer toured the physical plant. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story unit building that consists of two hallways with 24 resident rooms and shared Jack and Jill bathrooms. The residents’ bathrooms were recently renovated. There are common areas, dining/activity room, resident shower rooms, and kitchen for meal preparation and food service. In the front of the facility is the courtyard where there is a shaded patio seating area for residents to enjoy. The kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Emergency food and water supplies were stored separately in storage closets in the hallway. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire and smoke detectors are serviced and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. Resident bedrooms had the required furniture, bed (Annual continuation on LIC809C) linens and closet/drawer space to accommodate each client comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly. Grab bars were secure, and showers were free of mold/mildew. The water temperature measured between 116.0 to 116.2 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards; doorways were free of obstructions. First aid kit had all the required elements including bandages, dressing, tweezers, thermometer, and scissors. LPA Tea observed residents enjoying singing in the activity room. Activities are posted in the front desk area in English and Vietnamese with different activities for residents to participate. The residents like to play bingos and Asian games. They also go out on community outings like visiting the Asian shops, stores and going out to eat. LPA reviewed medication storage and administration. Medications are stored in carts that are locked and secured. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Administrator Assistant Paige Rohrer and copy of this report LIC809, 809-C, LIC858, LIC858-C, LIC859 and LIC9102TV was read and provided to the facility.the state’s words, verbatim · CDSS document, Sep 16, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff neglect resulted in a resident sustaining multiple fractures while in care.

On 05/19/25, Donna Gurriere, Licensing Program Analyst (LPA) contacted the licensee/administrator via telephone to deliver final findings regarding a complaint that was received 12/06/2023. LPA Gurriere spoke with Connor Kelley, Administrator and explained the purpose of the call. Staff neglect resulted in a resident sustaining multiple fractures while in care. During the interview process, the administrator, assistant administrator, four staff persons and two doctors were interviewed. In addition, documents were reviewed and obtained to include the Physicians Report, Incident Report, Death Certificate, and Medical Records of the resident (Resident 1). continued Unsubstantiated During the investigation of a complaint received on 12/06/23 it was reported that the medical records from Fountain Valley Hospital indicated that the resident presented at the hospital on 11/27/2023 with apparent abdominal discomfort for three days prior to admission. Upon initial evaluation, the resident underwent abdominal ultrasound demonstrating a 6-m nonobstructive right kidney stone with no other significant findings. The resident was found to have concerns for displaced rib fractures along the right lateral aspect of the ribs seven and eight. The displaced rib fractures may be either acute or subacute and not chronic. There is no documented history of falls. The medical records also indicated the fractures may be contributing to her abdominal discomfort as referred pain. Based on the information gathered during the investigation, there is not enough corroboration and or evidence to show that there is neglect/lack of care or supervision for the resident. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated. Licensee or administrator was advised a copy of this report will be sent via certified mail. Two copies of the report will be sent. Licensee or administrator is to sign and return a copy to the Orange County Regional Office.the state’s words, verbatim · CDSS document, May 20, 2025 · control 22-AS-20231206162230

Allegation investigated: Unqualified facility staff are administering injections to residents

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the four allegations listed above. LPA was greeted and granted entry by facility wellness director Paige Rohrer after explaining the purpose of the visit. An initial investigation visit took place on September 4, 2024. During the visit, LPA requested and obtained the facility census, staff roster, resident records for six admitted individuals including physician orders and medication administration records as well as reviewed the medication carts. Interviews with the facility's wellness director and administrator conducted. During the present visit, LPA requested the facility census and staff roster. Resident and staff interviews were conducted along with a tour of the two hallways of the facility. Additional record requested and reviewed. CONTINUED ON FORM LIC809-C Substantiated CONTINUED FROM FORM LIC809-A Regarding the allegation that Facility staff are not ensuring that medications are inaccessible to residents, the following has been concluded: During both unannounced facility visits, the two medication carts in use by facility staff were actively observed to be stationed at the med tech station in the facility and verified to be locked. No other medication was observed to be accessible outside of the secure central storage. Regarding the allegation that Facility staff are not ensuring that residents are taking medications as prescribed, the following has been concluded: The facility uses an electronic medication administration records. Facility staff demonstrated the use of the software to keep track of prescription and administration status during the present visit. LPA additionally verified that there were no discrepancies between the centrally stored medication and the records for four randomly selected residents. No discrepancies or administration errors were found during the review. Regarding the allegation that Facility staff are not meeting incontinence care needs of residents, the following has been concluded: Based on residents and staff interviews, facility observation and review of records conducted during the two facility visits, no instances of wet/dirty linen or articles of clothing were observed. There were also no occurrences of any lingering smells that could be associated with a failure to manage incontinence symptoms in residents during the visits. Individual care assignments for the previous two weeks were also obtained and reviewed and confirmed that adequate incontinence care is being provided and documented by staff. As a result, the three allegations listed are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC809 Regarding the allegation that Unqualified facility staff are administering injections to residents, the following has been concluded: Based on records reviewed, multiple residents admitted to the facility are diagnosed with insulin-dependent diabetes while also being assessed to be unable to self-monitor their glucose levels or self-inject insulin if necessary. The stated facility policy is to conduct hand over hand glucose monitoring and injections, however based on multiple staff and resident statements, injections are often conducted single-handedly by facility med techs. Title 22 restrictions for admission and retainer of residents with diabetes states that the facility may admit or retain residents with diabetes "if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional". Based on statements made during the visit, the restrictions are not met, therefore the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type B citation is issued on an attached form LIC809-D. An exit interview was conducted and a copy of this report along with attached citation and appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Nov 18, 2024 · control 22-AS-20240827122914

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87628(a) · Plan of correction due date: Dec 16, 2024

Per CCR Section 87628(a) on Diabetes: "The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing (...), and is able to administer his/her own medication (...) or has it administered by an appropriately (...) skilled professional. This requirement is not met as evidenced by multiple statements indicated med tech staff are conducting injections personally rather than hand-on-hand. This constitutes a potential risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Nov 18, 2024

Plan of correction: Licensee intends to apply for a Department-issued waiver in order to continue providing care to its residents who have become unable to manage their condition independently.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 47 non-ambulatory residents, with a hospice waiver for twenty-seven. Currently there are 42 residents, zero on hospice during today's visit. The Administrator (AD), Connor Kelley arrived shortly after to assist during the visit. At 9:15 AM, LPA Tea reviewed eight resident files and four staff files. Resident files and staff files contained all required documentation. Upon review of records, the facility is up to date with required quarterly emergency disaster drill, which was last conducted on August 6, 2024. LPA Tea along with AD Kelley toured the physical plant at 12:13 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story unit building that consists of two hallways with 24 resident rooms and shared Jack and Jill bathrooms. There are common areas, dining/activity room, resident shower rooms, and kitchen for meal preparation and food service. In the front of the facility is the courtyard where there is a shaded patio seating area for residents to enjoy. The kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Emergency food and water supplies were stored separately in storage closets in the hallway. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire and smoke detectors are serviced and maintained through a third-party company. Fire extinguishers are fully charged throughout the facility. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly. Grab bars were secure, and showers were free of mold/mildew. Annual continuation on LIC809C. Water temperature measured between 113.3 F degrees and 115.7 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. LPA Tea observed residents doing dancing and exercises in the activity room. Residents were also watching a movie in the afternoon. Activities are posted in the front desk area in English and Vietnamese with different activities for residents to participate. At 2:27 AM LPA reviewed medication storage and administration. Medications are stored in carts that are locked and secured. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Administrator Connor Kelley and copy of this report LIC809, 809-C, LIC858, LIC858-C and LIC859 was read and provided to the facility. .the state’s words, verbatim · CDSS document, Sep 19, 2024

Allegation investigated: Resident sustained an unexplained fracture while in care of staff.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on February 22, 2024. LPA was greeted and granted entry into the facility and met with Medication Technician (MT) Daniel Lazareno. LPA explained the reason for the visit. This Department has investigated the complaint alleging that resident sustained an unexplained fracture while in care of staff. Resident 1 (R1) was admitted to the facility in October 20, 2022. Documents reviewed included the Physician Report (LIC602) dated March 01, 2023, for R1. Per Physician report R1’s diagnosis are osteoporosis and dementia. On November 27, 2023, R1 was admitted to Fountain Valley Hospital. The Hospital admitting diagnosis were abdominal pain, hyperkalemia, and dehydration. R1’s abdominal CT scan and chest x-ray demonstrated bilateral rib fractures including right lateral 7th and 8th ribs and left lateral 4th rib fracture. CONTINUED ON LIC9099-C... Unsubstantiated During the course of the investigation LPA reviewed documents including the Unusual Incident/Injury Report (UIIR) dated November 29, 2023, for R1. Per UIIR on November 27, 2023, R1 complained of abdominal pain and being unable to have a bowel movement. 911 was called and transported resident to Fountain Valley Hospital. During the interviews with Fountain Valley Hospital admission Doctor, it was reported that falls contributed to fractures most of the time but that R1’s severe osteoporosis condition could cause the fractures. Per admission Doctor a variety of things could have cause those fractures, to name a few, severe coughing, during transportation via ambulance, etc. Per admission Doctor R1’s kidney stone and significant amount of stool within the rectal vault also contributed to the pain while at facility. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to insufficient evidence. Therefore, the allegation has been deemed to be UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 5, 2024 · control 22-AS-20240222150108

Allegation investigated: Resident sustained unwitnessed fall at the facility.

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA met with Ruben Ramirez, Administrator and explained the nature of the visit. Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which included interviews conducted, physical plant tour, and copy of pertinent documents obtained. It is alleged resident sustained unwitnessed fall at the facility. Review of records obtained resident (R1) is able to ambulate in the facility with assistance from a front wheel walker. Appraisal/needs and services plan indicate that R1 uses a front wheel walker to ambulate, plan is to use cane, objective is to remind resident to keep ambulation Continued on LIC9099-C Unsubstantiated tools close at all times. Observe R1 for change of condition and assist R1 to meals if needed. Resident appraisal indicates R1 is non-ambulatory walker while ambulating. R1 has difficulty in hearing, but no hearing aids. R1’s speech is clear and language to make needs known. R1 does need assistance of areas for bathing, meal prep, laundry, and med management. R1 does toilet independently and able to do some of ADLS independently. R1 is alert and oriented with no cognitive defects and forgetfulness. Review of R1’s records has no indication that R1 required 1:1 assistance. R1 indicated that they were using the bathroom when they slipped and fell. Incident report submit to the Department indicated that when R1 was found by staff 911 was called immediately and R1 was assessed by paramedics and transferred to hospital for evaluation. Based on the information gathered during the investigation, the Department is unable to ascertain if the allegation 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. This report was reviewed with Administrator and a copy was furnished to the facility.the state’s words, verbatim · CDSS document, Feb 26, 2024 · control 22-AS-20211228104511

Allegation investigated: insufficient staffing to meet resident's needs Staff are not answering residents call lights timely

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA met with Ruben Ramirez, Administrator and explained the nature of the visit. Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegations. Findings are based upon this investigation which included interviews conducted, tour of phydical plant and copies of pertinent documents obtained. It is alleged that the facility has insufficient staffing to meet residents’ needs. Records review revealed that at the time of visit facility census was 32 and facility staff schedule showed the facility to have 12 caregivers on the schedule. The monthly caregiver staffing schedule reflected that there were five shifts per day and there was two to three caregivers scheduled per shift. Interview with Administrator indicated that all shifts had caregivers and Continued on LIC9099-C Unsubstantiated MedTech scheduled per shift. Title 22 regulation 87411(a) Personnel Requirements-General states: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment, and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. Interviews conducted with 5 of 5 residents indicated that they felt that staff assisted them when requested, didn’t have to wait too long for help and never had an issue with not getting the help they needed. It is alleged staff are not answering residents call lights timely. Interviews with 5 of 5 residents indicated that they didn’t feel like they had to wait too long when the call light was pressed. Residents indicated that when they needed or required a caregiver’s assistance that they would get it all the time. Residents furthermore indicated that they never had an occasion where they didn’t get help that was needed. Residents indicated that if they have to wait, they do but not for too long, they also indicated that they have never pressed the call light and not gotten help. Facility observation call light when pressed rings to the front facility staff and staff notifies the caregiver. When call light is pressed it was observed that the alert could be heard loudly over the loud speaker at the facility. LPA observed that alert could be heard with a door closed which could allow caregivers to hear the alert in the vent the front office staff was busy or away from the front. Based on the information gathered during the investigation, 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. This report was reviewed with Administrator and a copy was furnished to the facility.the state’s words, verbatim · CDSS document, Feb 26, 2024 · control 22-AS-20220804082401

Allegation investigated: Staff stole resident's money.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegation listed above. LPA was greeted and granted entry by facility staff after explaining the reason for the visit. An initial complaint investigation visit was conducted on November 15, 2023. LPA requested and obtained records for four residents in care in addition to a list of the current facility employees. LPA accompanied by administrator conducted a tour of the facility's physical plant. Facility administrator also provided LPA with the staff schedule for the month of November including all current facility employees. An interview with administrator was conducted. CONTINUED ON FORM LIC9099-C Unfounded CONTINUED FROM FORM LIC9099-A During the present follow-up visit, four resident interviews and four staff interviews were also attempted or conducted. Regarding the allegation that Staff yelled at residents, the following has been concluded: While it cannot be entirely ruled out that instances of yelling could have happened in the facility, none of the residents or staff members interviewed did corroborate the occurrence. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided. CONTINUED FROM FORM LIC9099 During the present follow-up visit, four resident interviews and four staff interviews were also attempted or conducted. Regarding the allegation that Staff stole resident's money, the following has been concluded: Based on interviews with a resident and with the facility administrator, one incident during which $10 in cash were misplaced was identified. While it could not be fully corroborated whether the funds had been recovered, it was however established that it had not been the result of theft conducted by a staff member. Additionally, the facility did not fail to safeguard the cash resources as they had not been entrusted to facility staff in the first place. As a result, the allegation is Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Nov 22, 2023 · control 22-AS-20231113105418