300606831-3-23-2023-22-AS-MSTC-CQK3U5-20230403183259

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300606831
Report Date: 03/23/2023
Date Signed: 03/23/2023 01:53:30 PM

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
12/15/2022 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221215100019

FACILITY NAME:	FREEDOM VILLAGE		FACILITY NUMBER:	300606831
ADMINISTRATOR:	MARIANNE CASINO/ J.NIBLETT		FACILITY TYPE:	741
ADDRESS:	23442 EL TORO ROAD		TELEPHONE:	(949) 472-4733
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	533	CENSUS: 62	DATE:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	09:51 AM
MET WITH:	Assistant Director-Jackie Arreaga		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not follow physician's orders
Staff did not facilitate medical tests for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit for the complaint received on 12/15/2022 for the allegations listed above for a continuation visit, and to deliver the findings. LPA De Perio explained reason for visit and was greeted by facility administrator (AD)-Joel Niblett, Assistant Director-Jackie Arreaga, Clinical Director-Jean Guevara and Assistant Director of Nursing-Marybeth Melby.

For this visit, there are a total of 62 residents in care (Assisted Living) of which 12 are on hospice.

LPA De Perio conducted a continuation of interviews, and documentation reviews and obtained copies of pertinent documents.

(SEE LIC9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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-20221215100019

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: FREEDOM VILLAGE	FACILITY NUMBER: 300606831
	VISIT DATE: 03/23/2023

NARRATIVE

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This department has investigated the complaint alleging that staff did not follow physician's orders. LPA conducted record reviews such as but not limited to: the resident's physician report, medication record, prescribed medication log (including PRN medication), incident reports, physician orders, staff roster, and resident roster. LPA conducted a total of 9 interviews, which consisted of staff, residents, and responsible parties. 9 out of the 9 interviews conducted did not corroborate with the allegation due to reporting that the facility does follow the physician orders. Responsible parties also reported that there were no concerns regarding not following physician orders. Per interview and record review, PRN medications are only given to a resident as needed, and that the resident must request for the medication prior to receiving it. LPA reviewed the PRN medication log of the resident (December 2022) and it has been documented that the facility staff did give the medication (Imodium) to the resident per request between the dates of 12/14/22-12/25/22. Based on observations and review of documents obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This department has investigated the complaint alleging that staff did not facilitate medical tests for resident. LPA conducted a total of 9 interviews, which consisted of staff, residents, and responsible parties. 9 out of the 9 interviews conducted did not corroborate with the allegation. 5 out of the 9 interviews reported that the facility is partnered with a company called "Trident Care", who provides services such as: x-rays, blood work, ultra sounds and urine testing to the residents at the facility, and that once results are received, Trident Care, the facility, the resident's physician and responsible parties (if applicable) remain in communication regarding the resident's condition and results. LPA conducted record reviews such as but not limited to: the resident roster, staff roster, the resident's physician report, resident's medical lab requests, and the resident's medical lab test results. Upon review, it was found that the physician or physician assistant signed the forms as verification that the resident's medical testing was completed and received. Based on observations and review of documents obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

For today's visit, no citations were issued. An exit interview was conducted with Assistant Director-Jackie Arreaga, Assistant Director of Nursing-Marybeth Melby, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

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