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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000049
Report Date: 03/08/2024
Date Signed: 03/08/2024 11:23:58 AM

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
08/28/2023 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230828081438
FACILITY NAME:HALL FAMILY HOMEFACILITY NUMBER:
306000049
ADMINISTRATOR:RON SALDAFACILITY TYPE:
735
ADDRESS:1922 WEST FLORA STREETTELEPHONE:
(714) 434-0100
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY:6CENSUS: 2DATE:
03/08/2024
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Diane Hall-LicenseeTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Due to staff neglect, resident sustained multiple pressure injuries while in care.
Staff did not ensure that resident was enrolled in a day program.
Staff did not ensure that resident attended doctor's appointments.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted a office meeting to deliver findings on an investigation completed by the Department. LPA greeted and met with Licensee Diane Hall and explained the reason for the meeting.

During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including Individual Program Plans and OC Global Medical Center records. The purpose of today’s visit is to deliver the findings regarding the above allegation. The investigation conducted revealed the following:

Client 1 (C1) was admitted to the facility on 10/01/1997. Licensee Diane Hall reported C1 has a skin condition diagnosis of Urticaria. C1 was being seen by a dermatologist as a result. Hall reported taking C1 to see the dermatologist up until April of 2023; however, C1’s dermatologist office confirmed C1’s last appointment was back in the year of 2021.
CONTINUED ON LIC9099-C...


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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-20230828081438
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: HALL FAMILY HOME
FACILITY NUMBER: 306000049
VISIT DATE: 03/08/2024
NARRATIVE
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Hall reported that C1 ran out of prescribed ointment cream back in June of 2023 but did not follow back up with the doctor’s office. Instead, Hall continued to purchase over the counter cream for C1’s wounds and four of four caregivers confirmed providing care for C1’s wounds despite them not being a skilled trained professional. Hall reported she felt the over the counter creams worked better than the prescribed creams.

Staff 1 (S1) reported sending Hall pictures of blood in C1’s stool but was told to give C1 Imodium and Pepto-bismal without reaching out to C1’s doctor. Staff further reported observing liquid for C1’s colonoscopy in the fridge but never being told by Hall to administer it to C1. Hall did not follow through with C1’s scheduled colonoscopy appointment. Hall was asked by Orange County Regional Center (OCRC) to provide documentation of C1’s doctor appointments but failed to provide requested documentation.

Hall stated a few months prior C1 was going a few days without passing stool followed by having chronic bouts of loose stool. On 08/02/2023 Hall took C1 to see her Primary Care Physician where they noticed C1 had pressure injuries that needed to get looked at.

C1 was taken to OC Global Medical Center. Upon being admitted, C1 was found to have multiple stage three and stage two pressure injuries including wounds on the upper right back, bilateral left and right foot and sacral area and stage two wounds on right and left gluteal area gallstones. The OC Global Medical Center wound care nurse further found scar tissue around the wounds from old healed pressure injuries resulting from infrequent repositioning. In addition to the wounds, C1 was diagnosed with pneumonia and blocked stool causing a leakage. C1 was placed on a feeding tube as a result of the pneumonia in an effort to give C1’s throat a rest to recover. C1’s wound care nurse from OC Global Medical Center, Primary Care Physician and Dermatologist all confirmed C1’s pressure injuries were unrelated to C1’s pre-existing skin condition.



Interviews with four of four staff and Hall confirmed C1 often would sit in the living room watching TV. Interviews with OCRC reported asking Hall to sign C1 up for a day program but that Hall never did. Hall reported she could not sign C1 up for a day program as all day programs were closed in 2020 due to the Covid pandemic; however, after approximately a year upon reopening C1 was still not signed up for a day program as requested by OCRC. Hall reported delaying C1’s enrollment due to needing to get C1 a California Identification Card and wanting to enroll C1 and the other facility clients all in the same day program.
CONTINUED ON LIC9099-C...
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20230828081438
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: HALL FAMILY HOME
FACILITY NUMBER: 306000049
VISIT DATE: 03/08/2024
NARRATIVE
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Hall was advised by OCRC that C1 and other clients in care would not be able to be enrolled in the same day program due to having different level’s of care. Despite this, Hall continued to delay C1’s enrollment in a day program.

Therefore, based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegations that due to staff neglect, resident sustained multiple pressure injuries while in care; Staff did not ensure that resident was enrolled in a day program; and staff did not ensure that resident attended doctor's appointments has been Substantiated.

The facility is being cited per Title 22, Division 6 of the California Code of Regulations.
A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f)

An exit interview was conducted, and a copy of this report, 9099-D Page, and appeal rights was given at the time of exit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20230828081438
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: HALL FAMILY HOME
FACILITY NUMBER: 306000049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2024
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision- The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidence by: Licensee failed to ensure C1’s received necessary care resulting in multiple stage three and stage two pressure
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Licensee agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.
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injuries and hospitalization with a feeding tube. This poses an immediate health risk to residents in care.
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Type A
03/11/2024
Section Cited
CCR
80075(a)
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Health Related Services.- The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidence by: Licensee failed to
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Licensee agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.
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ensure C1 was regularly seen by a dermatologist due to skin condition resulting in lapse in prescribed cream for treatment. This poses an immediate health risk to 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230828081438
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: HALL FAMILY HOME
FACILITY NUMBER: 306000049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
85079(c)
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Activities- The licensee shall ensure that clients are given the opportunity to attend and participate in community activities including but not limited to the following: …Community Service…Community events…Senior citizen groups, sports leagues and service clubs. This requirement was not
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Licensee to provide an updated Activies Calendar to LPA by POC due date.
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met as evidence by: Licensee failed to enroll C1 in a day program despite being told of the need by Regional Center of Orange County. This poses a potential risk to client’s personal rights.
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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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5