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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300606831
Report Date: 08/14/2023
Date Signed: 08/14/2023 04:22:11 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
09/28/2020 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200928144157
FACILITY NAME:FREEDOM VILLAGEFACILITY NUMBER:
300606831
ADMINISTRATOR:MARIANNE CASINO/ J.NIBLETTFACILITY TYPE:
741
ADDRESS:23442 EL TORO ROADTELEPHONE:
(949) 472-4733
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:533CENSUS: DATE:
08/14/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Joel Niblett, Administrator
Jennifer Suckiel, Executive Director		TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff failed to seek timely medical services

Facility failed to safeguard resident's personal item

Facility staff failed to notify resident's authorized representative after fall
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Kevin Saborit-Guasch conducted an unannounced subsequent complaint visit to this facility to deliver findings in the investigation of the above allegations. LPA was greeted and granted entry by facility administrator Joel Niblet after explaining the purpose of the visit and detailing the allegations. Executive Director Jennifer Suckiel was notified of the and assisted with the remained of the visit.

During the investigation interviews were conducted with the reporting party, Resident (R) 1’s family members, facility staff, Orange County Sheriff’s Department staff, and a witness. During the course of the investigation facility records were obtained and reviewed as well as hospice records and medical notes from R1’s physician.
Regarding the allegation that Facility staff failed to seek timely medical services and that Facility staff failed to notify resident's authorized representative after fall, the investigation revealed the following: R1 was a 93-year-old resident of Freedom Village Senior Living who resided independently at the facility.
CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 22-AS-20200928144157
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: FREEDOM VILLAGE
FACILITY NUMBER: 300606831
VISIT DATE: 08/14/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099
R1 was admitted to the Independent Living portion of Freedom Village on September 11, 2013. R1 was able to manage their own medications and did not require any assistance with Activities of Daily Living (ADLs). R1 was diagnosed with Myeloblastic Leukemia in 2015. R1 decided to decline further treatment and interventions such as transfusions and proceeded with hospice care. R1’s physician reported on his medical notes that by July 7, 2020, R1’s health had declined with shortness of breath and that R1 was becoming weaker due to anemia. On July 20, 2020, R1 independently contracted with Silverado Hospice for palliative care.

On July 30, 2020, the hospice staff reported that R1 was alert and ambulatory. On August 1, 2020, R1 sustained an un-witnessed fall. Staff S1 arrived to check on R1 after they called for help with their alert pendant. R1 informed S1 that they fell onto a bookshelf on their right side and complained of pain. S1 evaluated R1 and assisted R1 to their recliner. After the fall, R1 complained of pain and was unable to get up and unable to perform basic tasks. S2 was notified about the fall and they notified hospice and instructed facility staff to initiate two-hour welfare checks on R1. Staff written notes documented R1 remained in bed and was experiencing extreme pain. After the resident’s fall on 08/01/20, staff provided a narrative of the incident, including a red alert report which requires a signature from resident if they refuse transport to the hospital. No signature was included on the report obtained by the Department.

On August 2, 2020, staff contacted R1’s son to inform him that his mother’s health had declined. R1’s family came to visit R1 who was now bedridden with complaints of persistent pain. R1 refused to go to the hospital and her family respected her wishes. On August 3, 2020, at about 1030 hours, Hospice nurse S3 contacted the family to inform them that R1’s health had progressively declined. Family arrived at approximately 1130 hours and remained with R1 until they passed at approximately 1330 hours. Due to the rapid deterioration of R1’s health and excruciating pain they experienced, the facility failed to provide timely medical attention regardless of the resident receiving palliative care from hospice. R1 should have been treated for the injury sustained after their fall. Under Title 22, 87101 (7) "Hospice Care Plan" means the hospice agency's written plan of care for a terminally ill resident. The hospice shall retain overall responsibility for the development and maintenance of the plan and quality of hospice services delivered, R1’s fall and injury sustained was not part of R1’s hospice care plan. Under Title 22, Section 87101 regarding Falls, the facility failed to provide timely medical attention and did not report the fall to next of kin in a timely manner.
CONTINUED ON FORM LIC9099-C
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20200928144157
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: FREEDOM VILLAGE
FACILITY NUMBER: 300606831
VISIT DATE: 08/14/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099-C

The facility's failure to obtain required medical attention allowed R1 to experience unnecessary pain and injury following the fall sustained on August 1, 2020.

Regarding the allegation: Facility failed to safeguard resident's personal item, the investigation revealed the following. Interviews were conducted with R1’s family, facility staff, and hospice care staff. S2 informed R1’s son that S2 had removed R1’s wedding ring and placed it a box for the family. R1’s son received the box but when they opened it, R1’s wedding was not present in the box and some other jewelry was present that R1’s son did not recognize. S2 provided conflicting statements and after admitted to removing R1’s wedding ring, they later recanted that statement. S2 then sent an email confirming they had in fact removed R1’s wedding ring. However, upon removing the R1’s ring, there was no documentation describing what was removed and indicating where the ring was stored for safekeeping.

Based on the observations made, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Facility staff failed to seek timely medical services, Facility failed to safeguard resident's personal item, and Facility staff failed to notify resident's authorized representative after fall are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is/are being cited on the attached LIC 9099D. An Immediate Civil Penalty was additionally assessed on today September 8, 2023 for a violation of California Code of Regulations Section 87465(g) resulting in a resident's injury.

An exit interview was conducted with the facility representative and a copy of this report along with the appeal rights were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20200928144157
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FREEDOM VILLAGE
FACILITY NUMBER: 300606831
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2023
Section Cited
CCR
87465(g)
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The California Code of Regulations Section 87465(g) on Incidental Medical and Dental Care states that “The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health”.
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Licensee will provide staff an in-service training regarding this regulation by POC due date. Licensee to provide the name of the instructor, their title, and submit written proof of the staff training to LPA by POC due date.
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This requirement is not met as evidenced by: based on resident record review & interviews conducted the licensee failed to call 911 following R1’s unwitnessed fall on 08/01/2020. This poses an immediate risk to the health & safety of residents in care. CIVIL PENALTY ASSESSED ON 9/8/23
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The licensee to provide LPA a written statement indicating they have read this section of Title 22 regulation and how exactly they intend to adhere to it by POC due date.
Type B
09/11/2023
Section Cited
CCR
87211(a)(1)(A)
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The California Code of Regulations Section CCR 87211(a)(1)(A) on Reporting Requirements states that “A written report shall be submitted (…) to the person responsible for the resident within seven days of the occurrence of Death of any resident(…).”
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The Licensee is to ensure written reports are submitted to the Department pursuant to this regulation. The Licensee to provide LPA a written statement indicating they have read this section of Title 22 regulation and how exactly they intend to adhere to it by POC due date.
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This requirement is not met as evidenced by: based on resident record review & interviews conducted Licensee failed to submit Death Report until requested. Licensee also failed to report R1’s fall. This poses a potential risk to the health and safety of the residents in care.
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20200928144157
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FREEDOM VILLAGE
FACILITY NUMBER: 300606831
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2023
Section Cited
CCR
87218(a)(2)
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The California Code of Regulations Section 87218(a)(2) on Theft and Loss states that “The licensee shall ensure an adequate theft and loss program (…). A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost property
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The Licensee to ensure it always safeguards resident property. Licensee will provide staff an in-service training on regulations applicable to Theft and Loss by POC due date.
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(...).” This requirement is not met as evidenced by: based on observation and interview, Licensee failed to properly safeguard R1’s wedding ring. This poses a potential risk to the health and safety of the residents in care.
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 Licensee to provide the name and title of the instructor, and submit written proof of the staff training to LPA by POC due date.
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5