197608079-3-7-2024-28-AS-RORN-D3AMKB-20240312094026

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608079
Report Date: 03/07/2024
Date Signed: 03/07/2024 02:01:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2023 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230615135534

FACILITY NAME:	HEIGHTS SENIOR CARE, THE		FACILITY NUMBER:	197608079
ADMINISTRATOR:	SAYDA NAZ HAI		FACILITY TYPE:	740
ADDRESS:	690 PICAACHO DRIVE		TELEPHONE:	(562) 228-3063
CITY:	LA HABRA HEIGHTS	STATE: CA	ZIP CODE:	90631
CAPACITY:	6	CENSUS: 3	DATE:	03/07/2024
		UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Sayda Naz Hai – Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff admitted resident without resident's consent.
Staff did not follow the facilities visitor policy.
Staff allowed resident to leave the facility without verifying appropriate supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit regarding the above-mentioned allegations. LPA met with Sayda Naz Hai (Administrator) and Myra Johnson (Caregiver ) and explained the reason for the visit.

The investigation consisted of the following:

During initial visit dated 6/16/23 LPA Luis Mora interviewed the Administrator and Staff 1. LPA Mora obtained copies of Resident 1 (R1) entire file.

During subsequent visit 3/7/24 LPA Herrera obaitned copies of staff and resident roster and visitation policy, interviewed Administrator, and 3 residents. (Resident #1(R1) was not available for interview)

(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230615135534

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HEIGHTS SENIOR CARE, THE	FACILITY NUMBER: 197608079
	VISIT DATE: 03/07/2024

NARRATIVE

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The investigation revealed the following:

Allegation: Staff admitted resident without resident's consent.
It is alleged that Resident #1 (R1) was admitted to the facility by unauthorized individuals. Per information gathered on hospital records, hospital that transferred R1 to facility, it was stated that R1's brother was the Power of Attorney (POA). LPA interviewed brother of R1 and they stated that they are not and have never been a POA for R1, however, they are the next of kin and the Responsible Party for medical decisions for R1. R1's brother further stated that R1 at the time of admission was in recovery and unable to make their own decisions, therefore, R1's brother made the decision of admitting R1 to facility and signed all paperwork to do so, R1 was aware of the move and went willingly. R1's Physician's report dated 5/19/23 states that R1 "is not decisional for medical care", and indicates that bother assists with medical decisions.

Allegation: Staff did not follow the facilities visitor policy.
It is alleged that the facility did not follow visitor policy as the required sign out was not done. LPA obtained a copy of the facilities visitor policy and no where in the policy does it state that one must sign in and out during visitation. LPA interviewed Administrator and 1 Staff and both stated that facility allows visitation with family members and friends, facility encourages these visits and that all staff are aware of who the responsible parties for each resident are and would not allow residents to leave without proper supervision if needed. LPA interviewed 2 residents and both stated that they are allowed visitation with family and are able to leave into the community with their responsible parties/family.

Allegation: Staff allowed resident to leave the facility without verifying appropriate supervision.
It is alleged that R1 left the facility unassisted with girlfriend and staff did not follow behind R1 to ensure safety. LPA reviewed admission agreement for R1 and girlfriend identified as wife on paperwork was indicated as a responsible party for resident. During interview with R1's brother/Responsible Party, they stated that although girlfriend was not able to make medical decisions for R1 visitation was granted as family lives out of state and girlfriend lives near by and is able to be a support for R1. LPA obtained a copy of a signed letter from R1's girlfriend stating they are taking R1 from facility on 6/10/23. Administrator stated that since girlfriend was listed as a responsible party during admission she was able to take R1 from facility, there fore, R1 left facility supervised with their Responsible Party.
(Continued on LIC9099-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230615135534

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HEIGHTS SENIOR CARE, THE	FACILITY NUMBER: 197608079
	VISIT DATE: 03/07/2024

NARRATIVE

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Based on statements and interviews conducted with staff and residents, review of R1's files and facility Visitation Policy, there was not enough supportive evidence to concur with the reported allegations.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
Exit interview held, and a copy of this report was provided to Caregiver Myra Johnson.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

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