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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000889
Report Date: 05/15/2023
Date Signed: 05/15/2023 12:59:42 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
05/09/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230509150421
FACILITY NAME:SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CAFACILITY NUMBER:
306000889
ADMINISTRATOR:JO DEE GIBSONFACILITY TYPE:
741
ADDRESS:16850 E. BASTANCHURY ROADTELEPHONE:
(714) 577-9281
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:76CENSUS: 27DATE:
05/15/2023
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Kat Farris and Linda Lida SpicerTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff are mismanaging residents' medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility by Executive Director Kat Farris and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed residents and staff as well as reviewed and obtained pertinent documentation such as medication orders and physician reports. Regarding the allegation that staff are mismanaging residents' medications, the investigation revealed the following: LPA reviewed the Electronic Medication Administration Record (MAR) during the visit. Upon review of Resident 1's (R1) MAR, it was revealed that NOC shift staff have missed sign offs on the record. LPA reviewed medication on hand versus the MAR. R1 is prescribed Ocusoft Lid Scrub, daily. Staff did not sign 05/02/23, 05/07/23, 05/10/23, and 05/13-05/14/23. Current container was started on 05/09/23 with 30 pieces as indicated on packaging. LPA counted pieces in box and observed 33 pieces. R1 is also prescribed Calprotect Ointment, daily. Staff did not sign on 05/02-05/03/23, 05/07/23, 05/10/23 CONTINUED ON LIC 9099C DATED 05/15/2023.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
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 4
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
05/09/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230509150421

FACILITY NAME:SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CAFACILITY NUMBER:
306000889
ADMINISTRATOR:JO DEE GIBSONFACILITY TYPE:
741
ADDRESS:16850 E. BASTANCHURY ROADTELEPHONE:
(714) 577-9281
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:76CENSUS: 26DATE:
05/15/2023
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Kat Farris and Linda Lida SpicerTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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9
Due to language barrier staff can't communicate with residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility by Executive Director Kat Farris and explained the reason for the visit. Wellness Director Linda Lida Spicer was present as well.

During the course of the investigation, LPA toured the facility, interviewed residents and staff as well as reviewed and obtained pertinent documentation such as medication orders and physician reports. Regarding the allegation that due to language barrier staff can't communicate with residents, the investigation revealed the following: During the course of the investigation, LPA interviewed staff and residents. Four out of four staff and three out of three residents deny communication barriers with NOC shift staff. Interviews indicated Staff 1 (S1) has an accent but is able to speak English and has no issues with communication. S1 has been employed at the facility since 2003 and Executive Director states no complaints or issues with the staff during tenure at the facility. The only new staff, S2, is fluent in English and all interviewed confirm no issue with communication. Therefore the allegation is deemed UNFOUNDED, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was emailed to facility representative..
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20230509150421
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: SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CA
FACILITY NUMBER: 306000889
VISIT DATE: 05/15/2023
NARRATIVE
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and 05/13-05/14/2023. Due to the nature of the ointment container, LPA is unable to determine whether the ointment had been administered. LPA reviewed medication training records during the investigation and the NOC shift staff have current medication training. Facility uses a computer based training for some medication training which the staff utilize. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was emailed to facility administrator along with appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 22-AS-20230509150421
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: SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CA
FACILITY NUMBER: 306000889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2023
Section Cited
CCR
87464(f)(4)
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Basic services shall at a minimum include: Personal assistance and care as needed by the resident.., with those activities of daily living such assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement is not being met as evidenced by:
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Licensee to provide medication re-training and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure residents are being provided assistance with medication. Staff did not administer R1's prescribed Ocusoft Lid Scrub on several occasions. This poses a potential health and safety 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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4