300613274-1-27-2021-22-AS-SSAS-BZ64UV-20210315192523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300613274
Report Date: 01/26/2021
Date Signed: 01/27/2021 03:30:16 PM

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
10/14/2020 and conducted by Evaluator Kathrina Chin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201014090030

FACILITY NAME:	PARK VISTA AT MORNINGSIDE		FACILITY NUMBER:	300613274
ADMINISTRATOR:	HAIDY MIKHAEL ANDRAWES		FACILITY TYPE:	740
ADDRESS:	2527 BREA BLVD		TELEPHONE:	(714) 256-8008
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92835
CAPACITY:	85	CENSUS: 61	DATE:	01/26/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Haidy Andrawes, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident sustained unwitnessed fall resulting in injuries and hospitalization.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kathrina Chin contacted the facility via telephone for the purpose of presenting the findings of the complaint investigation due to COVID-19 and pre-cautionary measures. LPA Chin identified herself and discussed the findings with Haidy Andrawes, Administrator.

Allegation 1- Resident sustained unwitnessed fall resulting in injuries and hospitalization. It was alleged that the fall resulted due to lack of care and supervision.

On October13, 2020, Resident 1(R1) was found on the bathroom floor by Staff 1(S1) R1 ambulates with the use of a walker. S1 stated that he did his rounds about 12 midnight and found the resident in the bathroom floor sitting up. Resident 1 was checked on around 10:30 PM and resident was on her couch while reading in the living room. R 1 lives in Assisted Living. S1 stated that he did not see any visible injuries and resident said that she was fine and asked her if she wanted to go to the hospital. R1 declined. Resident got her up and ambulated without any problems and went to bed. Range of motion was done. (Continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021

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-20201014090030

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: 01/26/2021

NARRATIVE

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LPA Chin interviewed S2 who is an LVN. S2 reported that she checked on R1 on October 13, 2020 at approximately 11 AM. At 9:30 AM, S2 check on R1 and the caregiver reported to S2 that R1 walked to the living room without any difficulty. S2 observed the R1 eating her breakfast and decided to return to do a body check after the resident finished her meal.

S2 went back at 11 AM in order to assess the resident. S2 observed a deformity on the hip(like a bulge) which had minimal bruising to the area. She further explained that R1 can still ambulate without difficulty and had no pain. S2 assessed the resident in bed and resident complained of pain on left leg with pain 5 out of 10 in the groin area. She contacted 911 emergency at approximately 11:30 AM. She told the ambulance of unwitnessed fall at midnight and had no pain at the time. R1 was returned to skilled nursing in the same community. R1 returned to Assisted Living. R1 sustained a rib fracture and no hip fracture. R1 returned to Assisted Living on October 23, 2020.

LPA reviewed R1's medical assessment, Needs and Services plan and Fall Risk and Acknowledgment.

LPA Chin interviewed the responsible party of R1 who felt that facility staff provided adequate care and supervision for R1 and have no concerns with the facility. LPA interviewed R1 who stated that she does not remenber the fall. She stated that she is able to walk around with her walker and she likes living at the facility.

As such, there is insufficient evidence to corroborate whether the above allegation has occurred. Based on the information gathered during the investigation and review of all documents obtained, the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

An exit teleconference was conducted with Haidy Andrawes, AD and LPA Chin discussed and read this report. A copy of this report will be provided via email along with the appeal rights. Haidy Andrawes agreed to review the report and return a signed copy.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021

LIC9099 (FAS) - (06/04)

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