306002482-2-27-2024-22-AS-LMOA-D2X4Z4-20240229183206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002482
Report Date: 02/27/2024
Date Signed: 02/27/2024 12:05:07 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
10/04/2022 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221004145131

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: 6	DATE:	02/27/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Carol Wilson- Administrator		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Staff is not providing adequate care and supervision to individuals in care.
Residents are left in their soiled clothing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit to continue the complaint investigation and deliver the findings into the above allegations. LPA was allowed entry by Caregiver Karen Mae Moralde and stated the purpose of the visit. Administrator (Admin) Carol Wilson arrived at 10:37am. On October 10, 2022, LPA Claudia Gutierrez initiated the complaint and delivered the findings for three out of the five allegations. LPA Cho made an unannounced subsequent visit on February 14, 2024, to continue the investigation for the remaining two allegations. During the course of the investigation, LPA Cho conducted interviews with two out of the six residents and three staff. LPA was unable to conduct interviews with three residents due to their refusal and/or medical conditions. LPA also obtained copies of pertinent documentations such as the resident/staff rosters, face sheets, and physician’s reports. Additional records such as the Preplacements and Reappraisals were also obtained on today’s date. The investigation revealed the following:

Continued on LIC9099-C...

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: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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-20221004145131

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: CAREWELL MANOR	FACILITY NUMBER: 306002482
	VISIT DATE: 02/27/2024

NARRATIVE

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It is alleged that the staff is not providing adequate care and supervision to the individuals in care. During the visit conducted on February 14, 2024, from 3:15pm to 5:30pm, LPA Cho observed six residents and two caregivers on duty. The Administrator was also on premises upon LPA’s arrival. Per LPA’s observations, caregivers were actively assisting the residents during the visit today and on February 14, 2024. Per review of the appraisals, it was documented that two out of the six residents need special observation/night supervision. Based on the interviews conducted, one out of the two residents indicated that care and supervision is not provided after 7:00pm. Two out of the three staff interviewed indicated that care is only provided upon request when their shift ends at 7:00pm. Both staff also indicated breaks are taken at staggered times to ensure residents’ needs are met throughout the day, however routine checks are not conducted after 7:00pm.

It is alleged that the residents are left in their soiled clothing. Based on the observations made on February 14th during the diaper inspection requested by LPA, LPA along with the staff observed that the diaper for one out of six residents was visibly wet at 3:34pm evidenced by the yellow and heavy appearance. The stool was also observed to be impacted in the rectum. During today’s inspection with the staff approximately 9:40am, all diapers were dry. Per interviews conducted on February 14, 2024, one out of the two residents indicated that requests for diaper changes would go unanswered after 7:00pm until the next morning. Three out of the three staff interviewed indicated that routine checks are conducted every two hour interval during the day while checks during the nocturnal hours are not conducted unless requested.

Based on LPA’s investigation, although residents are routinely checked every two hours during the day and upon request during the day and after 7:00pm, residents who are non-verbal, confused, and disoriented are unable to verbalize their needs. Documentation also noted that the two out of the six residents need special observation/night supervision to ensure that their needs are being met at all times.

Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Staff is not providing adequate care and supervision to individuals in care and Residents are left in their soiled clothing are deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are being cited on the attached LIC 9099D.
An exit interview was conducted with Administrator Carol Wilson, and a copy of this report including the LIC9099C, LIC9099D, and 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: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20221004145131

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: CAREWELL MANOR	FACILITY NUMBER: 306002482
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/03/2024 Section Cited CCR 87464(f)(1)(c)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c)… (c) “…means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living…” which “includes assistance with taking medications, money management, or personal care.” This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that they will submit the schedule for the nocturnal shift to LPA via email by POC due date.
	8 9 10 11 12 13 14	Based on record review and interviews, one out of the two residents and two out of the three staff confirmed that care and supervision is not provided at all times which poses a potential Health, Safety, and Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Type B 04/03/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in a Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs …” This requirement was not met as evidenced by:	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	Based on observations and interviews, LPA and staff observed that diaper for one out of the six residents were soiled during the inspection which poses a potential Health, Safety, and Personal Rights risk to persons in care.	8 9 10 11 12 13 14	Administrator stated that they will create and submit a copy of the toileting log to LPA via email by 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.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

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