306000295-8-2-2022-22-AS-AORZ-CHCSNH-20220816140131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000295
Report Date: 08/02/2022
Date Signed: 08/02/2022 12:44:35 PM

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
06/29/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20210629113400

FACILITY NAME:	KARLTON RESIDENTIAL CARE CENTER		FACILITY NUMBER:	306000295
ADMINISTRATOR:	ELENA WEINER		FACILITY TYPE:	740
ADDRESS:	3615 WEST BALL RD.		TELEPHONE:	(714) 236-1170
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	76	CENSUS: 45	DATE:	08/02/2022
		UNANNOUNCED	TIME BEGAN:	12:01 PM
MET WITH:	Elena Weiner and Barbara Weiner		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Resident sustained multiple falls while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry by Administrator Elena Weiner and explained the reason for the visit. Licensee Barbara Weiner was present as well.
During the course of the investigation, LPA August interviewed Administrator Weiner as well as reviewed and obtained pertinent documentation such as physician report and hospital paperwork. Regarding the allegation that resident sustained multiple falls while in care, the investigation revealed the following: On June 23, 2021, Resident 1 (R1) was exhibiting confusion, poor gait, loss of appetite and loss of balance. R1 was experiencing insomnia as well. R1 was noted to have no injuries and a urinalysis was performed. R1's physician was contacted and follow up was scheduled. Facility utilized a bed alarm for resident. On June 24, 2021, R1 was exhibiting more confusion and lost balance on the edge of the bed. R1 was sent out to the hospital for an evaluation. The resident was cleared to come back to the facility and a one on one care companion was put on the resident for approximately one week. On June 30, 2021 R1 was sent out again for altered consciousness as resident was R1 CONTINUED ON LIC 9099C DATED 08/02/2022.

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: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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-20210629113400

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: KARLTON RESIDENTIAL CARE CENTER	FACILITY NUMBER: 306000295
	VISIT DATE: 08/02/2022

NARRATIVE

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experiencing heightened confusion. R1 returned from the hospital with a diagnosis of Progressive Dementia and a medication change to address the insomnia. Once resident was able to sleep again and resumed eating, the resident returned to baseline. Per physician report dated 09/20/2020, R1 is diagnosed with Dementia and Parkinson's Disease. R1 is currently residing at a skilled nursing facility for wound care. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with and a copy of this report was provided to facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

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