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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001808
Report Date: 08/05/2020
Date Signed: 08/05/2020 04:48:41 PM



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
03/18/2020 and conducted by Evaluator James August
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200318121859
FACILITY NAME:MILKY WAY GUEST HOMEFACILITY NUMBER:
306001808
ADMINISTRATOR:CYNTHIA VITALFACILITY TYPE:
740
ADDRESS:1748 W. SALLIE LN.TELEPHONE:
(714) 772-7494
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 3DATE:
08/05/2020
UNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Cynthia Vital, Licensee/AdministatorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not properly feed resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jim August contacted the facility via video-telephone to conclude a complaint investigation via telephone due to COVID19 and precautionary measures. LPA identified himself and discussed the purpose of the call, the elements of the allegation and investigatory findings with Licensee/Administrator (AD) Cynthia Vital. Regarding the allegation "Staff did not properly feed resident", the investigation revealed the following: It was alleged that facility staff did not allow Resident #1 (R1) to swallow their food before introducing another spoonful. Interview with witness revealed witness believed on one occassion, R1 had not finished swallowing their food as staff provided another bite of food. However, interview with staff revealed staff was monitoring R1's throat for swallowing motions as well as verifying R1's mouth was empty before providing another spoonful of food. 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, therefore the allegation is unsubstantiated. An exit interview was conducted with AD Vital via telepohone and a copy of this report along with LIC 811- Confidential Names List was provided to AD Vital via email and an electonic email read receipt confirms receiving these documents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James AugustTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020
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 7
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
03/18/2020 and conducted by Evaluator James August
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200318121859

FACILITY NAME:MILKY WAY GUEST HOMEFACILITY NUMBER:
306001808
ADMINISTRATOR:CYNTHIA VITALFACILITY TYPE:
740
ADDRESS:1748 W. SALLIE LN.TELEPHONE:
(714) 772-7494
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 3DATE:
08/05/2020
UNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Cynthia Vital, Licensee/AdministatorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Severe neglect resulting in resident developing multiple pressure injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jim August contacted the facility via video-telephone to conclude a complaint investigation via telephone due to COVID-19 and precautionary measures. LPA identified himself and discussed the purpose of the call and the elements of the allegation and investigation with Licensee/Administrator (AD) Cynthia Vital. Regarding the allegation "Severe neglect resulting in resident developing multiple pressure injuries", the investigation revealed the following: Per review of hospice records pertaining to Resident #1 (R1), there was no documentation of injuries sustained as a result of neglect. Review of R1's hospice records further revealed R1 had a pressure injury to the right heal upon admission that received treatment and was healed while R1 resided at the facility. Record review also indicated R1 had a wound to the forehead at the time of admission that was also treated and healed during residency at the facility. Interview with witnesses and staff both revealed R1 had extremely fragile skin which was prone to tearing and bruising. This agency has investigated the complaint alleging severe neglect resulting in resident developing multiple pressure injuries. CONTINUED ON LIC9099C...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James AugustTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 22-AS-20200318121859
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: MILKY WAY GUEST HOME
FACILITY NUMBER: 306001808
VISIT DATE: 08/05/2020
NARRATIVE
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We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with AD Vital via telephone and a copy of this report along with LIC 811- Confidential Names List was provided via email and an electronic read receipt confirms receipt.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James AugustTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
03/18/2020 and conducted by Evaluator James August
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200318121859

FACILITY NAME:MILKY WAY GUEST HOMEFACILITY NUMBER:
306001808
ADMINISTRATOR:CYNTHIA VITALFACILITY TYPE:
740
ADDRESS:1748 W. SALLIE LN.TELEPHONE:
(714) 772-7494
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 3DATE:
08/05/2020
UNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:Cynthia Vital, Licensee/AdministatorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident confined to bedroom for a long period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jim August contacted the facility via video-telephone to conclude a complaint investigation via telephone due to COVID-19 and precautionary measures. LPA identified himself and discussed the purpose of the call and the elements of the allegation and investigation with Licensee/Administrator (AD) Cynthia Vital. Regarding the allegation "Resident confined to bedroom for a long period of time", the investigation revealed the following: Interviews conducted with staff as well as witnesses revealed Resident #1 (R1) was routinely transferred between their bed and a recliner/couch which was located within their bedroom. Interviews also revealed R1 was provided their meals either while sitting on the recliner/couch or while in bed. Review of hospice records indicated hospice staff observed R1 in their room and more specifically in the recliner/couch in their room. Interview with staff revealed R1 was not provided the opportunity to enjoy the outside yards of the facility due to behavioral outbursts which the facility was afraid may disturb the neighbors. LPA found no evidence that R1 had spent any significant time outside of their individual room. Based on LPA's interviews which were conducted and record review, the (CONTINUED ON LIC 9099 C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: James AugustTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 22-AS-20200318121859
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: MILKY WAY GUEST HOME
FACILITY NUMBER: 306001808
VISIT DATE: 08/05/2020
NARRATIVE
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preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code Of Regulations, Title 22, Division 6 is being cited on the attached LIC 9099D.
An exit interview was conducted with AD Vital via telephone and a copy if this report along with LIC 811- Confidential Names List along with LIC 9058- Appeal Rights was provided to AD Vital via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James AugustTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20200318121859
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: MILKY WAY GUEST HOME
FACILITY NUMBER: 306001808
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2020
Section Cited
HSC
1569.269(a)(10)
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Enumerated Rights; severability- (a)
Residents of residential care facilities for the elderly shall have all of the following rights:(10) To be free from...involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by:
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Licensee states they will ensure that R1 is not sequestered to their room and will be able to utilize other areas of the facility.
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The Licensee did not ensure R1 was free from involuntary seclusion. Based on interviews and record review, R1 was routinely sequestered in their bedroom and not permitted to utilize the other areas of the facility. This poses a potential personal rights 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: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James AugustTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020
LIC9099 (FAS) - (06/04)
Page: 7 of 7