300600977-11-28-2022-22-AS-SSAS-CM33KX-20221212171951

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300600977
Report Date: 11/28/2022
Date Signed: 11/28/2022 02:28:58 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/14/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20210114162557

FACILITY NAME:	TOWN & COUNTRY		FACILITY NUMBER:	300600977
ADMINISTRATOR:	STEPHENIE JUKIC		FACILITY TYPE:	741
ADDRESS:	555 E. MEMORY LANE		TELEPHONE:	(714) 547-7581
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92706
CAPACITY:	328	CENSUS: 72	DATE:	11/28/2022
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Stephanie Jukic		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not ensure a resident attended dialysis treatment
Resident sustained a fall while in care

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced complaint visit to deliver findings on the above allegations. LPAs identified themselves and discussed the purpose of the visit with Director Stephanie Jukic. During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report and care plan. Regarding the allegation that staff did not ensure a resident attended dialysis treatment and resident sustained a fall while in care, the investigation revealed the following: Resident 1 (R1) is diagnosed with End Stage Renal Disease and attended dialysis 3 days a week. R1 was sent out for the resident's regular dialysis appointment on Monday, January 11, 2021. During the health screen at the dialysis center, R1 had an elevated temperature and was denied treatment. Facility was advised via family member that R1 could not obtain treatment due to fever and would have to be rescheduled at the designated Covid-19 dialysis center. Resident admitted back into the facility and was noted to have cold symptoms, fever and coughing. R1 was put in isolation in the resident's room and physician was contacted. Around 4:16 PM, R1 was found on the bathroom floor by caregiver. CONTINUED ON LIC 9099C DATED 11/28/2022

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

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-20210114162557

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: TOWN & COUNTRY	FACILITY NUMBER: 300600977
	VISIT DATE: 11/28/2022

NARRATIVE

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Resident stated tripping and fell on floor. Resident was sent out to the hospital where the resident tested positive for Covid-19 and subsequently passed away on 01/19/2021. Resident did not have the ability to get rescheduled for dialysis as the resident was hospitalized. Per Appraisal Needs and Services and Resident Appraisal, R1 used a front wheeled walker to ambulate but was able to ambulate without the assistive device. Resident 1 was not a fall risk and per interviews with staff, the resident had no prior falls. Therefore the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC9099 (FAS) - (06/04)

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