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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002233
Report Date: 10/04/2022
Date Signed: 10/04/2022 02:31:45 PM

Substantiated


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
06/17/2022 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220617093626
FACILITY NAME:RAINBOW COTTAGEFACILITY NUMBER:
306002233
ADMINISTRATOR:HANH PHAMFACILITY TYPE:
740
ADDRESS:24301 LYSANDA DRIVETELEPHONE:
(949) 455-7376
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
10/04/2022
UNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Hanh PhamTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident not being provided adequate service.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to deliver the findings on the above allegation. At 1:31pm, LPA was greeted and granted entry by Caregiver Ma Alojado. Caregiver Imelda Navarro was also present who informed Administrator (Admin) Hanh Pham of LPA's arrival. Admin arrived at the facility around 1:55pm and discussed the purpose of the visit. The following are the findings of the investigation which involved interviews and records review:

On June 16, 2022, the Department received a complaint alleging that Resident 1 (R1) was not provided adequate service. R1 has a diagnosis of mild dementia, diabetes, a history of UTI, and was placed with a catheter on March 22, 2022. On May 5, 2022, R1 was admitted to Saddleback Hospital due to a malfunctioning catheter. R1 acquired a cough and the chest x-ray revealed Atelectasis of the right lung. The oxygen order was issued and required use for 24 hours since R1’s discharge. R1 was admitted to Silverado Hospice on May 22, 2022 due to a terminal diagnosis of Atherosclerotic Heart Disease and received routine care at the facility. [Continued on LIC9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
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 3
Control Number 22-AS-20220617093626
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: RAINBOW COTTAGE
FACILITY NUMBER: 306002233
VISIT DATE: 10/04/2022
NARRATIVE
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On June 15, 2022, Staff 3 (S3) was hired to work as a reliever for the primary caregivers, Staff 1 (S1) and Staff 2 (S2), after completing three days of training on June 1st, June 6th, and June 7, 2022. S1 stated that S3 completed one in-service training at the facility on June 14, 2022 for approximately 1 to 1.5 hours instructed by S1 and S2. S3 stated that the oxygen compressor in the living room was accidentally turned off not knowing it belonged to R1. Per S1, S3 stated that the oxygen was turned off for 3-5 minutes. S3 admitted that the oxygen was accidentally turned off for a few minutes. When S1 and S2 entered the facility and observed the oxygen was turned off, S2 rushed to turn it back on while S1 went to check in on R1.

Based on LPA’s information gathered through interviews of witnesses, review of records, observations, and S3 admission statement that R1’s oxygen was turned off, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. See LIC9099D for cited deficiency.

A deficiency is cited today as per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted with the Administrator Hanh Pham, and a copy of this report along with the LIC9099C, LIC9099D, 811s, and the appeal rights were provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20220617093626
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: RAINBOW COTTAGE
FACILITY NUMBER: 306002233
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2022
Section Cited
CCR
80065(a)
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80065(a) Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs.

This requirement is not being met as evidenced by:
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The Administrator will have a plan in writing regarding handling resident’s oxygen that will also be discussed during the staff training. Proof of training sheet will indicate the names of staff's that have attended and will be submitted to LPA by POC due date.
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Based on observation, records review, and interviews, S3 did not demonstrate competency by turning off R1’s oxygen compressor on June 15, 2022. S3 admitted to turning off the oxygen compressor for 3-5 minutes which poses a potential Health, Safety, and Personal Rights risk to the persons 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) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3