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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002648
Report Date: 03/06/2025
Date Signed: 03/06/2025 03:12:41 PM

Unsubstantiated


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
08/24/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220824143608
FACILITY NAME:HUNTINGTON ELDER-CARE IFACILITY NUMBER:
306002648
ADMINISTRATOR:CARMEN G. ACHIMFACILITY TYPE:
740
ADDRESS:20141 BUSHARD STREETTELEPHONE:
(714) 964-9628
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 5DATE:
03/06/2025
UNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Carmen AchimTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Facility lacked care and supervision resulting in resident sustaining a fracture
Staff failed to provide residents medical information to paramedics
Staff did not inform authorized representative of incident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit on this day for the purpose of delivering findings into the above allegations. On this day LPA was greeted and met with Administrator Carmen Achim and explained the reason for the visit.
On August 24, 2022, the Department received a complaint alleging facility lacked care and supervision resulting in resident sustaining a fracture; staff failed to provide residents medical information to paramedics; and staff did not inform authorized representative of incident in a timely manner. A health and safety visit was conducted by the Department on August 25, 2022, and an investigation initiated. The investigation determined as follows:
Per Physician Report dated December 01, 2020, Resident 1 (R1) is non-ambulatory and unable to transfer themselves in and out of bed. R1’s Preplacement Appraisal dated November 06, 2020, notes R1 as having an acute and chronic respiratory failure with hypoxia, has difficulty walking, osteoarthritis, low back pain, and obesity. R1 is also noted as having dementia. CONT ON LIC 9099C DATED 03/06/2025
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
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-20220824143608
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: HUNTINGTON ELDER-CARE I
FACILITY NUMBER: 306002648
VISIT DATE: 03/06/2025
NARRATIVE
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Identification and Emergency Information Form dated December 03, 2020 documents R1 as requiring the use of a walker or wheelchair to ambulate. It also documents R1’s daughter-in-law. On December 17, 2022, R1 was found laying on their bedroom floor by Caregiver 1 (C1) after responding to a noise coming from R1’s bedroom. R1 reported they were trying to reach for a mirror in the night stand when their knee gave out, causing them to fall. C1 called Administrator Carmen Achim who is reported to live five minutes away. Upon arrival and finding R1 in pain, 9-1-1 was contacted. R1 was admitted to Hoag Hospital Newport Beach where they were admitted with a diagnosed fracture of right pubis and displaced fracture of anterior column (iliopubic) of right acetabulum. R1 was assessed by hospital staff to require a skilled nursing facility. Per Huntington Beach Fire Department 911 response records and documentation, response to R1’s fall occurred on December 17, 2022 at 6:42 PM at Huntington Elder Care home facility. Huntington Beach Fire Department scanned into records the documentation provided to them by Huntington Elder Care home which included R1’s insurance cards, medication lists and dosages, and R1’s identification and emergency information form. Per interview with facility staff, three of five staff interviewed denied any neglect occurred. The two remaining staff reported they were not present when the fall occurred. Interviews with three of three staff present during the time of the incident reported there was confusion over who was going to notify R1’s responsible party of the fall, which caused a delay in notification; However, once realized, R1’s responsible party was informed of R1’s hospitalization within 24 hours of fall occurring.
Medical records obtained from hospital notate that R1’s family was contacted by the hospital social worker and no concerns of neglect were expressed. Documentation obtained from Administrator Achim included emails and text messages from R1’s responsible party in which they acknowledge an understanding that R1 is a fall risk and know they will have falls. It was further expressed that they felt “Your caregivers have been great…”

Based on interviews conducted and records reviewed, the allegations that facility lacked care and supervision resulting in resident sustaining a fracture; staff failed to provide residents medical information to paramedics; and staff did not inform authorized representative of incident in a timely manner are deemed to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of this report and confidential names list was provided to Administrator.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
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