306001407-1-25-2024-22-AS-SSAS-CZYVEH-20240130152223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001407
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:29:35 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
07/07/2021 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210707111504

FACILITY NAME:	EMERALD COURT		FACILITY NUMBER:	306001407
ADMINISTRATOR:	PATRICIA GIRAY-GUSTIN		FACILITY TYPE:	740
ADDRESS:	1731 MEDICAL CENTER		TELEPHONE:	(714) 778-5100
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	299	CENSUS:	DATE:	01/25/2024
		UNANNOUNCED	TIME BEGAN:	02:06 PM
MET WITH:	Kathleen Panganiban		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility failed to provide care and supervision to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings for the complaint investigation into the allegation listed above. LPA met with Assistant Executive Director Kathleen Panganiban and explained the reason for the visit. The investigation into the allegation, facility failed to provide care and supervision to resident revealed the following. Resident 1 (R1) has been diagnosed with Dementia. The care plan states R1 has an increased risk for fall. R1's care plan dated 6/13/2021 states the staff will check on the resident every 2 hours and provide assistance when required. R1 can ambulate and according to the care plan they will escort the resident when needed and R1 can complete all transfers independently. According to R1’s care plan they are not provided a one-on-one caregiver. On July 4, 2021, R1 fell and was found by Staff 1 just outside the entrance of the facility. Staff 1 assessed R1 and called 911. Facility staff reported the resident was treated and returned the same day with no new orders. Staff 1 reported they did not see R1 fall and they don’t know how long they were there before they were discovered.

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)

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Control Number 22-AS-20210707111504

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

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After R1 fell and Staff 1 saw them, 911 was contacted and R1 was transported to the hospital and treated. Facility staff notified R1’s family and primary care physician. The Agency received an Unusual Incident Report (LIC 624) reporting the incident on 7/08/2021. LPA interviewed R1 who did not recall the incident and there were no visible injuries on R1. 5 out of 5 staff interviewed reported that all residents are checked on regularly and properly cared for. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegations may have happened or are 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)

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