300600977-5-30-2023-22-AS-AORZ-CSCQBE-20230531120126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300600977
Report Date: 05/30/2023
Date Signed: 05/30/2023 10:03:18 AM

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
12/29/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20211229132131

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: 195	DATE:	05/30/2023
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Stephanie Jukic		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Resident sustained injury from the fall as a result of lack of care and supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA identified herself and discussed the purpose of the visit with Director Stephanie Jukic.
During the course of the investigation, LPA toured the facility, interviewed witness, staff, and Administrator as well as reviewed and obtained pertinent documentation such as physician report dated 06/07/2021 and facility progress notes dated 12/15/2021. Regarding the allegation that resident sustained injury from the fall as a result of lack of care and supervision, the investigation revealed the following: Resident 1 (R1) had been residing in the Independent Living side of the facility with their spouse since 06/07/2021. R1 was receiving no assistance in activities of daily living and was completely independent per Administrator, witness, and physician report dated 06/07/2021. R1 had recently transferred from a skilled nursing facility to the Independent Living with a diagnosis of Multiple Myeloma- In Remission. No change in condition was noted and R1 CONTINUED ON LIC 9099C DATED 05/30/2023

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: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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-20211229132131

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: 05/30/2023

NARRATIVE

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remained Independent. On 12/15/2021, R1’s spouse had called the front desk of the Independent Living and stated they had woken up and R1 was observed on the floor. The Assisted Living staff responded, and R1 was found to be unresponsive. 911 was called and R1 was transferred out to UCI Hospital. The facility would later be notified that R1 had a brain hemorrhage and subsequently passed away on 12/17/2021 due to Acute Traumatic Intracranial Hemorrhage (bilateral subdural hematoma) from the fall. R1’s physician report dated 06/07/2021 indicates R1 is ambulatory with no history of falls and needs no transfer assistance. R1 can manage their own medications without any assistance. The facility protocol is to check in with Independent Living residents three times a day. Residents are asked to put a card outside their room daily by 8 AM. If the card is not observed, staff will check in on the resident. The two other checks are at lunch and dinner times. Residents can access assistance if needed by pulling the cord in their room. Once the cord is activated, an assisted living staff will respond to the resident’s room. Although R1 did sustain a fall at facility, interviews conducted and records reviewed indicate R1 was Independent. The facility had no reason to suspect R1 was at risk for a fall and therefore did not neglect R1.

Based upon interviews and a review of records, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was emailed to facility representative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

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