300613274-10-27-2020-22-AS-SSAS-BV2682-20201103193426

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300613274
Report Date: 10/20/2020
Date Signed: 10/27/2020 11:56:17 AM

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
07/22/2020 and conducted by Evaluator James August

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200722163941

FACILITY NAME:	PARK VISTA AT MORNINGSIDE		FACILITY NUMBER:	300613274
ADMINISTRATOR:	HAIDY MIKHAEL ANDRAWES		FACILITY TYPE:	740
ADDRESS:	2527 BREA BLVD		TELEPHONE:	(714) 256-8119
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY:	85	CENSUS: 65	DATE:	10/20/2020
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Haidy Andrawes, Administrator		TIME COMPLETED:	09:57 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident fell due to lack of supervision from staff.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jim August contacted the facility via telephone to conclude a complaint investigation via telephone due to COVID-19 and precautionary measures. LPA identified himself and discussed the purpose of the call and the elements of the allegation with Administrator Haidy Andrawes.
The 10-day visit was completed on July 29, 2020.
The investigation into the allegations that a resident fell due to lack of supervision from staff revealed the following:
LPA August conducted the initial investigation on July 29, 2020. During the investigation, LPA interviewed one witness, Administrator Haidy Andrawes and one (1) staff as well as reviewed and obtained pertinent documents and a video of the incident.
Witness 1 (W1) alleges that resident 1 (R1) was had a fall on June 13, 2020 at approximately 4:55PM. W1 stated that R1 was a high fall risk. W1 stated that the facility failed to properly supervise R1 which led to the fall and subsequent injuries.
CONTINUED ON LIC9099C DATED OCTOBER 27, 2020...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

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 2

Control Number 22-AS-20200722163941

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: PARK VISTA AT MORNINGSIDE	FACILITY NUMBER: 300613274
	VISIT DATE: 10/20/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Administrator Haidy Andrawes and staff 1 (S1) confirmed that R1 had a fall on June 13, 2020 at approximately 4:55PM. S1 locked R1’s wheelchair and momentarily walked away. R1 then got up from her wheelchair and fell to the ground. The staff member returned to find R1 on the ground.

LPA August reviewed video surveillance of the incident. The video shows S1 moving R1 to a living room area in her wheelchair and stopping her next to another resident in a wheelchair. S1 walked away at this point, however there are other staff members coming and going from the video surveillance. At approximately 4:53PM, R1 stands up from her wheelchair unattended and falls to the ground. S1 returns at approximately 4:55PM to find R1 on the ground.

LPA reviewed and obtained facility documents, including a “Fall Risk Facts & Acknowledgment” indicating that “assisted living does not provide one-on-one supervision”. The acknowledgement indicates that “falls and other injuries can occur from time to time. If you are not comfortable with the type of environment, we suggest you consider a higher level of care”. The acknowledgement was signed on April 6, 2020 by R1's responsible party.

This report is being amended to change the findings from "unfounded" to "unsubstantiated". The resident did not have a 1 on 1 caregiver assigned to her from the facility. The family of the resident hired a private 1 on 1 caregiver that was not present at the facility when R1 fell. As such, there is insufficient evidence to corroborate whether the above allegation has occurred. With the information obtained through the means described above, we have found the above allegation unsubstantiated. Although the allegation may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Administrator Haidy Andrawes via video-telephone and a copy of this report was provided to Administrator Andrawes via email. Administrator Andrawes to sign all pages of the report and return the signed copy to LPA August within 24 hours.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2