306001407-1-25-2024-22-AS-MSTC-D2264V-20240131192921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001407
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:06:27 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
02/08/2022 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220208165528

FACILITY NAME:	EMERALD COURT		FACILITY NUMBER:	306001407
ADMINISTRATOR:	DAIZEL C GASPERIAN		FACILITY TYPE:	740
ADDRESS:	1731 MEDICAL CENTER		TELEPHONE:	(714) 778-5100
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	299	CENSUS: 240	DATE:	01/25/2024
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Kathleen Panganiban		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident is being hit while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings for the complaint investigation into the allegation listed above. The investigation into the allegation, resident is being hit while in care, revealed the following. It was alleged that Resident 1 (R1) was hit by someone at the facility sometime on or before 2/5/2022. On 2/4/2022 R1 was sent to the hospital due to displaying symptoms of a stroke. R1 was treated at the hospital and returned to the facility at 4:00 am on 2/5/2022. On 2/5/2022 at 8:00 am R1 was displaying symptoms of a stroke. R1 was sent to the hospital and admitted for treatment. R1 returned to the facility on 2/07/2022. R1’s responsible party reported that they visited R1 daily from 2/07/2022 until their passing on 7/09/2022. R1 passed away on 7/9/2022 and was never interviewed. R1’s responsible party reported they never witnessed any abuse and never saw any signs of abuse on R1. 5 out of 5 staff members interviewed reported they never abused R1 and never saw any abuse. LPA could only make contact with one hospice nurse who reported they never witnessed any abuse and never saw any signs of abuse.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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 2

Control Number 22-AS-20220208165528

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: EMERALD COURT	FACILITY NUMBER: 306001407
	VISIT DATE: 01/25/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Administrator reported that none of the staff reported any incidents concerning R1 and have not reported any signs of abuse. No evidence was gathered that supports the allegation, therefore the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of the report provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2