306000059-12-13-2023-22-AS-MSTC-CYQ5DL-20231220185203

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000059
Report Date: 12/13/2023
Date Signed: 12/13/2023 09:44:42 AM

Unsubstantiated

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
11/25/2020 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20201125153256

FACILITY NAME:	PARK REGENCY RETIREMENT CENTER		FACILITY NUMBER:	306000059
ADMINISTRATOR:	JENNIFER TURGEON		FACILITY TYPE:	740
ADDRESS:	1750 W. LA HABRA BLVD.		TELEPHONE:	(714) 441-1164
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	168	CENSUS: 77	DATE:	12/13/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Ashley Willet		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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Resident developed a severe pressure injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff as well as reviewed and obtained pertinent documentation such as hospice notes and physician report. Regarding the allegation that resident developed a severe pressure injury while in care, the investigation revealed the following: Resident 1 (R1) admitted into hospice care on 09/15/2020 with a diagnosis of Senile Degeneration of Brain. Per hospice notes, resident was being seen by hospice approximately every 7-10 days. Between 10/07/2020 and 12/28/2020, resident was seen by hospice nineteen times. On 09/16/2020, resident was observed to have a blister on lateral side of right calf with instructions given for antibiotic ointment. There is no documentation of any pressure injury on the resident’s back or any wound care being provided by hospice or facility staff. LPA interviewed two staff who were familiar with the resident and two out of two denied resident ever having
CONTINUED ON LIC 9099C DATED 12/13/2023

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

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-20201125153256

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 REGENCY RETIREMENT CENTER	FACILITY NUMBER: 306000059
	VISIT DATE: 12/13/2023

NARRATIVE

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any pressure injury including at end of life. Witness interviewed confirmed this as well. Both staff members indicate at time of complaint, resident was ambulatory, always out of the resident’s room and participating in socialization. Hospice notes confirm resident’s ambulatory status. Physician report dated 09/15/2020 indicated a diagnosis of Dementia with no documentation of any pressure injury or history of pressure injury. Resident’s Needs and Care Plan at time of complaint has no documentation of skin breakdown or wound care. Based on record review and interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

LIC9099 (FAS) - (06/04)

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