306000130-11-1-2021-22-AS-SSAS-CFP4AA-20220623185534

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000130
Report Date: 11/01/2021
Date Signed: 11/01/2021 02:33:49 PM

Substantiated

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
10/25/2021 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20211025094012

FACILITY NAME:	ANA MARIE'S GUEST HOME		FACILITY NUMBER:	306000130
ADMINISTRATOR:	SHUMAN, ANA M.		FACILITY TYPE:	740
ADDRESS:	1304 E. CHAPMAN		TELEPHONE:	(714) 744-9555
CITY:	ORANGE	STATE: CA	ZIP CODE:	92866
CAPACITY:	6	CENSUS: 1	DATE:	11/01/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Paola Olivares		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff failed to seek immediate medical treatment when resident fell
Staff did not adequately manage resident's glucose

INVESTIGATION FINDINGS:

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Licensing Program Analyst Michelle Reed arrived at the facility to discuss the complaint allegations. Upon arrival, LPA met with Staff Paola Olivares. Ana Shuman was contacted via telephone but did not answer the phone or come to the facility. Interviews were conducted and records were reviewed.

R1 was admitted into the facility on 8/20/18. According to records reviewed, R1 took medication to monitor her blood sugar and was required to have a RCS diet. R1 could not manage her own glucose testing and a skilled professional was not assisting. According to Staff R1's glucose levels were not monitored as R1 was taking medication. Staff stated that R1 did not have a special diet and liked to eat alot of fruit

On 10/21/21 R1 had an unwitnessed fall in her bedroom. Staff found R1 on the floor face down. R1 had a bump on her head and stated that she was in pain. She asked staff to call her Daughter. Staff contacted Daughter but did not contact 911. R1's face and eyes immediately began to bruise. On 10/22/21 at approximately 1:40pm, R1 was found in bed very confused and her speech was very slow. 911 was

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

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-20211025094012

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: ANA MARIE'S GUEST HOME	FACILITY NUMBER: 306000130
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/02/2021 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Staff understand that 911 should be contacted immediately, especially for an unwitnessed fall resulting in a head injury. Licensee will provide certification that staff have been trained on emergency medical treatment. Family should not dictate 911 calls.
	8 9 10 11 12 13 14	On 10/21/21 at approximately 12pm R1 was found by staff in her room face down. R1 complained of head and face pain and had a lump forming on her head. Staff contacted R1's Daughter and failed to immediately contact 911. 911 was contacted on 10/22/21 due to R1's confusion. This poses a immediate health and safety risk.	8 9 10 11 12 13 14
Type A 11/02/2021 Section Cited CCR 87628(a)(b)(4)	1 2 3 4 5 6 7	Diabetes-The licensee shall be permitted to accept or retain a resident who has diabetes if the resident can perform her own glucose testing and is able to administer her own medication or has it administered by a skilled professional. Additionally, a modified diet shall be provided as prescribed by a resident's physician.	1 2 3 4 5 6 7	Licensee will ensure residents with diabetes are having their blood sugar levels tested by a skilled professional if a resident cannot conduct their own testing. Licensee understands that If a special diet is prescribed by a physician then the diet should be provided at all times. Understanding of this subsection will be provided via certification.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Licensee/Staff failed to assist R1 in managing her glucose levels. A skilled professional was not testing glucose levels and an RCS diet was not being followed as prescribed by R1's physician(See medical assessment)	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20211025094012

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: ANA MARIE'S GUEST HOME	FACILITY NUMBER: 306000130
	VISIT DATE: 11/01/2021

NARRATIVE

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immediately called and R1 was taken to the hospital. R1 had low blood sugar and a hematoma.

Based upon interviews and a review of records, the preponderance of evidence standard has been met and the above allegations are substantiated.

See attached LIC9099D for cited deficiency per California Code of Regulations, (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report and appeal rights were provided to Ms. Olivares.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC9099 (FAS) - (06/04)

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