300606398-6-2-2022-22-AS-MVAO-CG4QET-20220707120652

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300606398
Report Date: 06/02/2022
Date Signed: 06/02/2022 11:21:34 AM

Unsubstantiated

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
06/16/2021 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210616090845

FACILITY NAME:	YORK RETIREMENT HOMES, INC.		FACILITY NUMBER:	300606398
ADMINISTRATOR:	JACOBSEN, DONALD		FACILITY TYPE:	740
ADDRESS:	22391 LOMBARDI		TELEPHONE:	(949) 770-1348
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS: 0	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	10:11 AM
MET WITH:	Donald Jacobson, Administrator		TIME COMPLETED:	10:45 PM

ALLEGATION(S):

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-Staff did not seek timely medical help for resident

-staff refused to assist resident after a fall

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez contacted the facility via tele-visit due to facility being closed. Visit was conducted to deliver findings for the investigation into the above identified complaint allegations. LPA spoke with Donald Jacobsen, Administrator and explained the purpose of the telephone call.

During the course of this investigation LPA conducted the following; interviews were conducted with staff, interview with residents, a review of resident records was completed, and a copy of pertinent documents obtained.

It is alleged that there was neglect of a resident. Base on the conflicting information received from interviews, the lack of information regarding the incident in question, and the lack of corroborating witness to the incident, LPA is unable to determine if the alleged violation occurred as reported.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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-20210616090845

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: YORK RETIREMENT HOMES, INC.	FACILITY NUMBER: 300606398
	VISIT DATE: 06/02/2022

NARRATIVE

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Based on the information mentioned above, 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.

An exit interview was conducted with facility representative via tele-visit and a copy of this report was provided to facility representative via email. An electronic email read receipt or response to email indicating as received as confirmation.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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