198602384-7-24-2020-11-AS-JHAD-BS8NVR-20200806104822

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602384
Report Date: 07/24/2020
Date Signed: 07/24/2020 04:58:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/08/2020 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200708084002

FACILITY NAME:	FOUNTAINVIEW AT GONDA WESTSIDE		FACILITY NUMBER:	198602384
ADMINISTRATOR:	STEWART, BRADLEY THOMAS		FACILITY TYPE:	741
ADDRESS:	12490 WEST FIELDING CIRCLE		TELEPHONE:	(424) 216-7788
CITY:	PLAYA VISTA	STATE: CA	ZIP CODE:	90094
CAPACITY:	286	CENSUS: 241	DATE:	07/24/2020
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Charlette Ofrecio, Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility is refusing to pick up resident from the hospital

INVESTIGATION FINDINGS:

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On 7/24/2020 at 11:50 AM, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint investigation to render investigation findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Charlette Ofrecio, the facility administrator.

The investigation consisted of the following: 7/17/2020 at 2:05 PM LPA and LPM conducted telephonic visit, during investigation requested Residents (R1’s) file, most recent Physicians Report, Emergency Identification Sheet, recent Needs and Service Plan, Resident & Staff Roster and any resident’s current reports sent via email to LPA & LPM by 7/20/2020.
Due to insufficient information not available at this time, further investigation is needed.

The investigation revealed the following:
LIC9099-C is on the next page

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020

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 11-AS-20200708084002

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FOUNTAINVIEW AT GONDA WESTSIDE	FACILITY NUMBER: 198602384
	VISIT DATE: 07/24/2020

NARRATIVE

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Facility is refusing to pick up resident from the hospital:

On 7/8/20 at 1:55 PM and on 7/17/20 the Administrator Charlette Ofrecio was interviewed regarding the allegation. The Administrator denied refusing to accept the resident back from the hospital. She stated the resident had a change in condition and was being discharged from the hospital with a Catheter. The Administrator stated she reviewed Title 22 and determined the resident needed a higher level of care until the catheter could be removed. The Administrator stated she was working with R1’s family to either temporarily relocate R1 or request an exception from CCL. On 7/8/2020, R1 Responsible Party was interviewed regarding the allegation and stated the facility did not refuse to accept R1 back. She sated they were working with her because R1 had a Catheter. On 7/8/2020, SW was interviewed and stated the facility never evicted R1 but stated they must adhere to Tittle 22 regarding the Catheter. SW stated initially the doctor wanted R1 to go to a Skilled Nursing Facility Temporarily, but the family refused. The doctor stated the resident could return to the facility with Home Health and a 24-hour Caregiver, but the facility stated they would have to get permission from CCL. Estimated date was 7/10/20 R1 was discharged and stayed with family until 7/16/2020. On 7/16/2020 R1 Catheter was removed and R1 has returned to the facility.

Based on interviews and documentation during the investigation Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated or unfounded

A telephonic exit interview was conducted with the administrator and hard copy was provided via email for records

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020

LIC9099 (FAS) - (06/04)

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