300600977-11-2-2023-22-AS-AORZ-CXEQBC-20231109110118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300600977
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:52:25 PM

Substantiated

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
10/27/2023 and conducted by Evaluator Andrea Mendivil

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231027121729

FACILITY NAME:	TOWN & COUNTRY		FACILITY NUMBER:	300600977
ADMINISTRATOR:	STEPHANIE JUKIC		FACILITY TYPE:	741
ADDRESS:	555 E. MEMORY LANE		TELEPHONE:	(714) 547-7581
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92706
CAPACITY:	328	CENSUS: 205	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Stephanie Jukic- Director of Residential Care Services		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Due to lack of supervision, a resident eloped from the facility

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Stephanie Jukic and explained the reason for the visit.

The department received a complaint on 10/27/2023 and initial 10 day visit was conducted on 11/02/2023. During the visit LPA interviewed staff and a resident, LPA obtained copies of physician reports and incident reports for Resident 1 (R1).

Based on report R1 exited the second story of the Memory Care community via a door on the south side. R1 was able to make it down the street and found by a local business manager and returned to the facility. R1 was then assessed and uninjured. R1's family was notified of the incident and R1 was placed on 1:1 care for a month.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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-20231027121729

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: 11/02/2023

NARRATIVE

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Per review of R1's physicians report R1 is not able to leave the facility unassisted and listed to have wandering behaviors once every few months. R1 resides in Memory Care on the 2nd floor. Per interviews with staff R1 has not tried to leave the facility in the past.

Based on interviews with Director of Residential Care Services Stephanie Jukic facility has conducted elopement drills once a month and a contracted company to come out and provided feedback to deter elopements. Stephanie stated they have ordered additional alarms for egress doors. Administrator also stated that the facility now has employees near each exit.

Therefore based on evidence through records reviewed and interviews the allegation Due to lack of supervision, a resident eloped from the facility is SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20231027121729

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/03/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by Resident 1 was able to elope from the facility.	1 2 3 4 5 6 7	Facility has implemented monthly elopment drills, contracted a company to assess the facility and provide suggestions to deter elopments. Facility to send LPA Mendivil elopment in services by POC due date.
	8 9 10 11 12 13 14	This poses an immediate safety and health risk to persons in care.	8 9 10 11 12 13 14
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3