306001960-10-10-2024-22-AS-LMOA-DAF6N7-20241026205702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001960
Report Date: 10/10/2024
Date Signed: 10/10/2024 04:47:36 PM

Substantiated

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
09/30/2024 and conducted by Evaluator Jessica Cho

COMPLAINT CONTROL NUMBER: 22-AS-20240930123543

FACILITY NAME:	ECLC - WAKE FOREST VILLA		FACILITY NUMBER:	306001960
ADMINISTRATOR:	ANGELITA DAVID		FACILITY TYPE:	740
ADDRESS:	233 WAKE FOREST RD.		TELEPHONE:	(714) 434-9489
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 5	DATE:	10/10/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Angelita David- Administrator Bernardito David- Caregiver		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Caregiver did not meet resident's needs.
Caregiver did not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of continuing the investigation and delivering the findings into the above allegations. LPA was greeted and allowed entry by Caregiver Juanita Sotta. Administrator Angelita David arrived approximately an hour later to assist with the investigation.

On October 3, 2024, LPA initiated the complaint investigation. During the course of the investigation, LPA interviewed a total of six staff and five residents. Out of the five resident interviews, LPA was unable to qualify one resident’s statement due to their medical condition. During the visit, copies of documentations were obtained for review which includes the Face sheets, Physician’s Reports, Needs and Services Plans, Admission Agreements for all residents, Medication Administration Records (MARs) for September 2024, Staffs’ Face Sheets, and other pertinent records. On today's date, LPA interviewed additional staff and audited the medications for all residents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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-20240930123543

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: ECLC - WAKE FOREST VILLA	FACILITY NUMBER: 306001960
	VISIT DATE: 10/10/2024

NARRATIVE

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Regarding the allegation, Caregiver did not meet the resident’s needs, the investigation revealed the following: Per interviews conducted with the residents, one out of the four residents reported facility not arranging their medical transportation. Based on the review of the needs and services plans of the resident, facility is responsible for arranging medical care transportation. Additionally, four out of the six staff corroborated with the allegation indicating that the resident has been arranging their own transportation recently. LPA conducted an audit of the medications for all residents. Based on the review, LPA observed medication errors in five out of five residents. Administrator acknowledged all errors during the audit.

Regarding the allegation, Caregiver did not treat the resident with dignity and respect. Although four out of the five residents did not corroborate with the allegation, Staff #1 (S1) confirmed yelling at Resident #1 (R1) during the interview. In addition, six out of the six staff confirmed S1 avoiding and ignoring the resident.

Therefore, based on LPA's interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Caregiver did not meet the resident’s needs and Caregiver did not treat resident with dignity and respect are deemed SUBSTANTIATED. Deficiencies are being cited as per the Title 22, Division 6, Chapter 8 of California Code of Regulations. See the attached LIC9099D.

An exit interview was conducted with Administrator Angelita David and Caregiver Bernardito David, and a copy of this report including the appeal rights were provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240930123543

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: ECLC - WAKE FOREST VILLA	FACILITY NUMBER: 306001960
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/18/2024 Section Cited CCR 87464(f)(2)&(6)	1 2 3 4 5 6 7	Type B: 87464 Basic Services (f) Basic services shall at a minimum include: (2) Safe and healthful living accommodations and services… & (6) Arrangements to meet health needs, including arranging transportation… This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that they will adhere to the needs and services plan of all residents and to submit a plan indicating the roles and responsibilities of each staff involved in medication prepping and passing. In addition, administrator will submit an Acknowledgement of Understanding of this said regulation as well as 87465 Incidental Medical and Dental Care to LPA via email by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, facility did not follow the needs and services plan by arranging transportation for one resident and making medication errors in five out of the five residents which poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Type B 10/18/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that the conflict will be resolved with resident and will submit an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.
	8 9 10 11 12 13 14	Based on interviews, S1 acknowledged yelling at the resident and six out of the six staff confirmed S1 avoid/ignoring resident which poses a potential Personal Rights risk to persons in care.	8 9 10 11 12 13 14

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: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

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