300603359-3-19-2024-22-AS-AORZ-D4DMZM-20240416100318

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300603359
Report Date: 03/19/2024
Date Signed: 03/19/2024 01:18:42 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
08/17/2023 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20230817105732

FACILITY NAME:	GOLDEN YEARS GUEST HOME THE		FACILITY NUMBER:	300603359
ADMINISTRATOR:	KRISTINE R LINARES		FACILITY TYPE:	740
ADDRESS:	14752 HOLT AVE		TELEPHONE:	(714) 731-6385
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	0	CENSUS:	DATE:	03/19/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:			TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Lack of care and supervision resulting in injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman attempted an unannounced visit to deliver findings on an investigation completed by the Department. LPA attempted contact via telephone with Licensee and was not successful.
During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including Physician Report and Pristine Hospice Records. The purpose of today’s visit is to deliver the findings regarding the above allegation. The investigation conducted revealed the following:
Resident 1 (R1) was admitted to the facility on July 14, 2023, and has a diagnosis of Dementia per Physician report dated July 14, 2023. Per Physician report resident requires 24/7 care and supervision and is noted as confused and unable to communicate their needs. R1 requires assistance with all activities of daily living (ADLs) and was receiving hospice services. On August 15, 2024, at around 7 AM, R1 was found by Staff 1 (S1) slipping through their bedrail, with half their torso slipping down and their arms embracing the railing. Staff 2 (S2) continued on LIC 9099C DATED 03/19/2024

Substantiated

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: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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-20230817105732

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: GOLDEN YEARS GUEST HOME THE	FACILITY NUMBER: 300603359
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/15/2024 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f)(1) Basic Services- Basic services shall at a minimum include: 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:	1 2 3 4 5 6 7	Licensee to forward a statement of understandin of the regulation to LPA by POC due date.
	8 9 10 11 12 13 14	Licensee failed to ensure R1 was adequately supervised as facility only employed one staff to cover two houses during the hours of 1900 to 0700 leaving R1 unsupervised for approximately two hours resulting in a fractur. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230817105732

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: GOLDEN YEARS GUEST HOME THE	FACILITY NUMBER: 300603359
	VISIT DATE: 03/19/2024

NARRATIVE

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who was on duty during the night reported checking on R1 around 4 AM and observing them sleeping soundly. An X-Ray was ordered by R1’s Hospice Doctor which confirmed R1 had an acute non displaced interarticular mid olecranon fracture due to fall. In addition, R1 was observed to have bruising to the right and left arms, chest and facial area.
Interviews with the facility House Manager described R1 as a fall risk and noted they were able to turn themselves in bed. Documents obtained from Pristine Hospice further confirmed R1 was evaluated to be at an increase risk for falls and had a history of falls within the three months prior to being admitted to the facility.

The facility is licensed for a total capacity of 15 of which are to be spread out over the two homes on the property. Per interviews conducted with caregivers, there is only one staff on duty during the hours of 1900 to 0700 hours for both houses on the property. The night of R1’s slip, S2 reported leaving the house in which R1 resides and going to the other house at around 5AM. Interviews with residents confirmed the facility has a call pendant to call caregivers for assistance; however, R1’s physician report indicates R1 is unable to communicate their needs. Interviews with the facility house manager confirmed they did not think R1 would’ve been able to use the call pendant as R1 was not mentally capable of taking care or comprehending.

Therefore, based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegations of Lack of care and supervision resulting in injury has been Substantiated.

The facility is being cited per Title 22, Division 6 of the California Code of Regulations.

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f)

The facility has been closed effective December 19, 2023. Attempts to reach Licensee to conduct an exit interview were unsuccessful. A copy of this report, 9099-D Page and appeal rights will be certified mailed to the Licensee’s last known address.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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