306002482-1-16-2025-22-AS-MSTC-DDG7MA-20250131204650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002482
Report Date: 01/16/2025
Date Signed: 01/16/2025 04:30:08 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
11/20/2024 and conducted by Evaluator Dwayne L Mason

COMPLAINT CONTROL NUMBER: 22-AS-20241120085349

FACILITY NAME:	CAREWELL MANOR		FACILITY NUMBER:	306002482
ADMINISTRATOR:	CAROL WILSON		FACILITY TYPE:	740
ADDRESS:	3330 W. STONYBROOK DRIVE		TELEPHONE:	(714) 827-8520
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	6	CENSUS: 5	DATE:	01/16/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Iren Creighton - VP of Operations		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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1. Staff do not have fingerprint clearance, 2. Staff insert suppositories to residents in care, 3. Staff did not maintain resident records, 4. Residents are not provided proper food service, 5. Staff did not inform resident's physician of resident's change of condition, 6. Staff did not ensure sufficient food items were available at the facility for residents in care, 7. Centrally stored medications are accessible to residents in care, 8. Staff do not have a fire evacuation plan at the facility, 9. Staff do not have an infection control plan at the facility, 10. Staff are not following reporting requirements, 11. Staff did not ensure resident's diapering needs were met 12. Staff consume liquor while on shift and 13. Staff left residents unattended

INVESTIGATION FINDINGS:

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This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned bove. LPA arrived at the facility and was greeted by facility staff. LPA met with Administrator Rafael Torres and explained the nature of the inspection.

The department received a complaint on 11/20/2024 alleging the following: 1. Staff do not have fingerprint clearance, 2. Staff insert suppositories to residents in care, 3. Staff did not maintain resident records, 4. Residents are not provided proper food service, 5. Staff did not inform resident's physician of resident's change of condition, 6. Staff did not ensure sufficient food items were available at the facility for residents in care, 7. Centrally stored medications are accessible to residents in care, 8. Staff do not have a fire evacuation plan at the facility, 9. Staff do not have an infection control plan at the facility, 10. Staff are not following reporting requirements, 11. Staff did not ensure resident's diapering needs were met, 12. Staff consume liquor while on shift and 13. Staff left residents unattended. (continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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 8

Control Number 22-AS-20241120085349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAREWELL MANOR	FACILITY NUMBER: 306002482
	VISIT DATE: 01/16/2025

NARRATIVE

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(Continued from LIC9099) On 11/26/2024 LPA conducted a visit to the facility to initiate investigation into the above allegations. LPA obtained copies of resident roster, staff roster, infection control plan, disaster plan, training records, personnel records, CPR certification, admission agreements and facility sketch. On 1/16/2025, LPA returned to the facility to continue the investigation. LPA obtained photos of the following documents: criminal record clearances, physician's reports and health screenings.

Regarding the allegation of "Staff do not have fingerprint clearance," LPA reviewed staff files and observed Criminal Record Clearances in all staff files. LPA also reviewed the facility's personnel records through Guardian and observed 6 out of 6 staff have been cleared to work at the facility.

Regarding the allegation of "Staff insert suppositories to residents in care," LPA interviewed the 5 residents in care and all of them stated the facility does not insert suppositories or other medication into them rectally.

Regarding the allegation of "Staff did not maintain resident records," the allegation indication LIC602s are missing or outdated in resident files. LPA observed LIC602s all resident files. 4 out of 5 LIC602s were created in 2024. 1 out of 5 LIC602s was created in December 2023.

Regarding the allegation of "Residents are not provided proper food service," LPA interviewed 5 residents in care. Of the residents interviewed all stated they are provided proper food service and have no complaints.

Regarding the allegation of "Staff did not inform resident's physician of resident's change of condition," LPA reviewed resident files and noted one resident with dementia. LPA observed an admission agreement for this resident stating they moved into facility on 7/24/2024. LPA observed a completed physician's report indicating the resident has dementia. This report was signed by the resident's physician and dated 8/23/2024.

Regarding the allegation of "Staff did not ensure sufficient food items were available at the facility for residents in care," LPA observed the food supply in the facility. LPA noted the facility has 7 day supply of non-perishable foods and a 2-day supply of perishable foods. LPA conducted interviews with 5 residents in care. Of the residents interviewed, all stated there is enough food in the facility and that they receive enough.

Regarding the allegation of "Centrally stored medications are accessible to residents in care," LPA observed medications to be locked in a kitchen cabinet behind a lock that requires a key to open. Of the residents and staff interviewed, all stated medication remains locked in the kitchen. (Continued on 2nd LIC9099-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 22-AS-20241120085349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAREWELL MANOR	FACILITY NUMBER: 306002482
	VISIT DATE: 01/16/2025

NARRATIVE

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(Continued from 1st LIC9099-C) Regarding the allegation of "Staff do not have a fire evacuation plan at the facility," LPA observed a completed LIC610E posted in the facility.

Regarding the allegation of "Staff do not have an infection control plan at the facility," LPA observed a completed LIC9282 posted in the facility.

Regarding the allegation of "Staff are not following reporting requirements," LPA reviewed documents and interviewed residents in care. Based on LPA's review and interviews, LPA could not determine if any incidents occurred that went unreported.

Regarding the allegation of "Staff did not ensure resident's diapering needs were met," LPA conducted interviews with 5 residents in care. Of the residents interviewed, 3 stated they wear diapers. Of these residents, all of them stated they are changed appropriately and when they need to be.

Regarding the allegation of "Staff consume liquor while on shift," LPA observed no liquor or consumable alcoholic products in the facility. LPA conducted interviews with 5 residents and two staff. Of the 7 individuals interviewed, all of them denied this allegation.

Regarding the allegation of "Staff left residents unattended," LPA conducted interviews with 5 residents in care. Of the the residents interviewed, all of them stated the staff do not leave them unattended and that there is always a staff member present at the facility. LPA conducted interviews with 3 staff. 3 said the staff do not leave residents unattended.

Based on observations made, interviews conducted and records reviewed there is insufficient evidence to support the allegations of "Staff do not have fingerprint clearance," "Staff insert suppositories to residents in care," "Staff did not maintain resident records," "Residents are not provided proper food service," "Staff did not inform resident's physician of resident's change of condition," "Staff did not ensure sufficient food items were available at the facility for residents in care," "Centrally stored medications are accessible to residents in care," "Staff do not have a fire evacuation plan at the facility," "Staff do not have an infection control plan at the facility," "Staff are not following reporting requirements," "Staff did not ensure resident's diapering needs were met," and "Staff consume liquor while on shift." Although the allegations may have happened or are valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation are UNSUBSTANTIATED. LPA reviewed this report with staff and provided a copy.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
11/20/2024 and conducted by Evaluator Dwayne L Mason

COMPLAINT CONTROL NUMBER: 22-AS-20241120085349

FACILITY NAME:	CAREWELL MANOR		FACILITY NUMBER:	306002482
ADMINISTRATOR:	CAROL WILSON		FACILITY TYPE:	740
ADDRESS:	3330 W. STONYBROOK DRIVE		TELEPHONE:	(714) 827-8520
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	6	CENSUS: 5	DATE:	01/16/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Iren Creighton - VP of Operations		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff lock facility doors to prevent residents from leaving
Staff did not complete required trainings
Staff facility records are falsified
Staff did not provide adequate medication assistance to residents in care

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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 8

Control Number 22-AS-20241120085349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAREWELL MANOR	FACILITY NUMBER: 306002482
	VISIT DATE: 01/16/2025

NARRATIVE

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(Continued from LIC9099) On 11/26/2024 LPA conducted a visit to the facility to initiate investigation into the above allegations. LPA obtained copies of resident roster, staff roster, infection control plan, disaster plan, training records, personnel records, CPR certification, admission agreements and facility sketch. On 1/16/2025, LPA returned to the facility to continue the investigation. LPA obtained photos of the following documents: criminal record clearances, physician's reports and health screenings.

Regarding the allegation of "Staff lock facility doors to prevent residents from leaving," LPA observed facility staff unlock and lock the front door to the facility from inside the facility with a key. Of the 5 Residents interviewed, 4 of them stated the facility door locks from the inside with a key.

Regarding the allegation of "Staff did not complete required trainings," LPA interviewed Staff 1. S1 stated they were hired at the facility in April of 2024. LPA reviewed S1's file and observed a completed in-service training for PRN medication administration. LPA observed no other completed trainings. LPA conducted interview with S1 and AD. Both stated S1 had not completed their required training. LPA interviewed S1 about their previous work experience. S1 stated they did not do food preparation or medication administration at their previous job. LPA determined S1 has not received training and does not have previous work experience in multiple areas related to their current role as caregiver

Regarding the allegation of "Staff facility records are falsified," LPA observed a CPR card for Staff 1. LPA contacted the company named on the CPR card. The company had no record of the reference number on S1's CPR card. The company representative stated anyone who completed their course will have valid login credentials to their website. S1 stated they have valid login credentials to the website but was unable to login. S1 stated the CPR card was falsified and that they did not complete CPR certification through the company named on the CPR card.

Regarding the allegation of "Staff did not provide adequate medication assistance to residents in care," LPA conducted interview with 5 residents in care. Of the residents interviewed, all of them stated they receive adequate medication assistance. Based on record review, the staff present at the facility at the time of the inspection has not received full medication administration training. Although the LPA observed record of this staff member attending an in-service training for PRN medication, the facility could not produce proof of any other medication training. S1 also stated they did not administer medication at their previous job. LPA determined staff are not providing adequate medication assistance to residents. (Continued on LIC9099-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 22-AS-20241120085349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAREWELL MANOR	FACILITY NUMBER: 306002482
	VISIT DATE: 01/16/2025

NARRATIVE

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(Continued from LIC9099-C)

The preponderance of evidence standard has been met. The allegations of "Staff lock facility doors to prevent residents from leaving," "Staff did not complete required trainings," "Staff facility records are falsified," and "Staff did not provide adequate medication assistance to residents in care" is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that violations have occurred.

An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 22-AS-20241120085349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAREWELL MANOR	FACILITY NUMBER: 306002482
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/16/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/30/2025 Section Cited CCR 87705(f)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: The Licensee did not comply with the section cited above due to the presence of a locked	1 2 3 4 5 6 7	The facility staff stated they will remove the lock from the exterior door by the assigned POC due date of 1/30/25.
	8 9 10 11 12 13 14	front door that requires a key to open from inside the facility. LPA determined the facility has not fulfilled the requirements to maintain a locked exterior door. The requirements are found in Title 22 Regulations 87705(f)(1)-(f)(4). This presents a potential personal rights and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 01/30/2025 Section Cited CCR 87411(d)	1 2 3 4 5 6 7	87411 Personnel Requirements-General (d)All personnel shall be given on the job training or have related experience in the job assigned to them. The Licensee did not comply with the section cited above due to the presence of a staff	1 2 3 4 5 6 7	The Administrator stated they will ensure all staff complete their required training. Administrator will document training with the following: staff participating, topics covered and date/time of training. Facility staff will submit this documentation to the Department by the assigned POC due date.
	8 9 10 11 12 13 14	member who is providing food preparation and medication administration without prior experience or training to do so. This poses a potential health and safety 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.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 22-AS-20241120085349

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAREWELL MANOR	FACILITY NUMBER: 306002482
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/16/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/30/2025 Section Cited CCR 87207	1 2 3 4 5 6 7	87207 False Claims; No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. The Licensee did not comply with the section	1 2 3 4 5 6 7	The Administrator stated they will remove the falsified CPR document from all files. The Administrator stated they will ensure there are no falsified documents in any of the facility records.
	8 9 10 11 12 13 14	cited above due to the presence of a falsified CPR certification. This poses a potential health, safety or personal righs risk to persons in care.	8 9 10 11 12 13 14
Type B 01/30/2025 Section Cited CCR 87411(c)(3)(D)	1 2 3 4 5 6 7	87411 Personnel Requirements-General(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training (3)(D) Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4).	1 2 3 4 5 6 7	The Administrator stated they will conduct an in-service training regarding medication administration and ensure all care staff attend. AD stated they will document the training with: staff in attendance, topics covered and date/time of training. AD stated they will submit proof of training to the
	8 9 10 11 12 13 14	The Licensee did not comply with the section cited above due to being unable to show proof that all staff who provide medication assistance have adequate medication administration training and/or experience. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14	Department by the assigned POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

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