300600816-8-20-2024-22-AS-AORZ-D8MVNV-20240830163547

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300600816
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:58:04 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/10/2024 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240510130330

FACILITY NAME:	ROWNTREE GARDENS		FACILITY NUMBER:	300600816
ADMINISTRATOR:	CLAUDIA LUSCA-BORCSA		FACILITY TYPE:	741
ADDRESS:	12151 DALE STREET		TELEPHONE:	(714) 530-9100
CITY:	STANTON	STATE: CA	ZIP CODE:	90680
CAPACITY:	280	CENSUS: 186	DATE:	08/20/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Kerri Clark, Director of Operations		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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-Facility caregiver used excessive force when restraining resident resulting in a hematoma and additional bruising.

INVESTIGATION FINDINGS:

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Licensing program analysts (LPAs) Ruth Martinez and William Vanegas visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrive at facility was greeted and granted entry by the receptionist. LPA spoke with Kerri Clark, Director of Operations and explained the purpose of the visit.

Findings are based upon this investigation which included file review, hospice records review, interviews conducted with staff and residents.

It has been alleged that the facility staff caused an injury to a resident. Interviews with 3 of 3 facility staff revealed that while resident R1 was being assisted with dressing for bed, R1 became aggressive and grabbed staff member S1’s wrist. S1 was able to call for help, and staff member S2 arrived and verbally

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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 22-AS-20240510130330

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROWNTREE GARDENS	FACILITY NUMBER: 300600816
	VISIT DATE: 08/20/2024

NARRATIVE

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persuaded R1 to release S1’s wrist. Despite this, R1 continued to display aggressive behavior, swinging their arms, and hitting their hand against the arm rest of the wheelchair. According to hospice records from Salus Hospice, dated April 26, 2024, to May 07, 2024, R1 refused to let the hospice nurse assess or provide care, which led to further combative behavior. A review of R1’s records indicate a history of agitation and combativeness towards staff during activities of daily living (ADLs), resistance to care, and inappropriate behaviors associated with dementia, such as kicking, swinging, and attempts to strike during ADL care. The only record describing R1’s injuries are hospice visit notes for May 07, 2024, indicating patient’s left arm observed with bruising from elbow to hand due to patient banging their hand and arm on the arm rest of wheelchair.

Based on the information gathered during the investigation, interviews and review of all documents obtained, 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 facility representative, and a copy was furnished to the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC9099 (FAS) - (06/04)

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