306001351-12-7-2023-22-AS-SSAS-CYG2LZ-20231212163022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001351
Report Date: 12/07/2023
Date Signed: 12/07/2023 01:21:15 PM

Unsubstantiated

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
11/16/2020 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201116161730

FACILITY NAME:	TESS LOVING HOME II		FACILITY NUMBER:	306001351
ADMINISTRATOR:	MARITES VILLANUEVA		FACILITY TYPE:	740
ADDRESS:	2785 E. DIANA AVE.		TELEPHONE:	(714) 630-0999
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY:	6	CENSUS: 5	DATE:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Marites Villanueva, administrator		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Resident suffered a fall resulting in a fracture.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the reason for the visit. Administrator Marites Villanueva was notified of the visit via telephone and arrived later to assist.

The initial complaint investigation was conducted remotely by LPA Lydia Martinez due to COVID-19 precautionary measures in place at the time. LPA requested copies of facility and resident records which were provided by the facility and received by the Regional Office on November 30, 2020.

A subpoena for hospital records was submitted and records were obtained. LPA Saborit-Guasch conducted additional interviews via telephone ahead of the present visit. Resident records were reviewed and two facility staff interviews were also conducted.
CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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-20201116161730

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: TESS LOVING HOME II	FACILITY NUMBER: 306001351
	VISIT DATE: 12/07/2023

NARRATIVE

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CONTINUED FROM LIC9099

Regarding the allegation that Resident suffered a fall resulting in a fracture, the following has been concluded: Based on documents reviewed and interviews conducted, it was determined that on November 12, 2020, resident R1 sustained a fall and was later transported to the Emergency Department at UCI Hospital. However, the evidence reviewed did not appear to corroborate any deficiency in the care and supervision provided by facility staff that would have been the cause for the fall and subsequent injury. At the time of the incident, R1 had been assessed to require a walker and was generally using it to ambulate in the facility. The physician report on file for R1 dated December 17, 2019 confirms that the resident was a "high risk for falls" and was being monitored as such.

As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is 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 to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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