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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003385
Report Date: 06/28/2021
Date Signed: 06/28/2021 02:01:36 PM



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
08/04/2020 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200804151931
FACILITY NAME:FAMILY CHOICE SENIOR CARE 4FACILITY NUMBER:
306003385
ADMINISTRATOR:VIRGILIO AGASFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:0CENSUS: 0DATE:
06/28/2021
UNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Shazad Khan, Licensee RepresentativeTIME COMPLETED:
12:13 PM
ALLEGATION(S):
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-Resident sustained multiple pressure injuries while in care
-Facility staff did not keep facility free of scabies
-Resident was left in soiled clothing for an extended period of time
-Facility staff did not ensure that resident’s medical equipment was in working order
INVESTIGATION FINDINGS:
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On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz contacted Licensee Representative, Shazad Khan and conducted a visit on this day for the purpose of delivering findings regarding the allegations listed above. This Complaint was investigated by the Department.
It was alleged the resident sustained multiple pressure injuries while in care; Facility staff did not keep facility free of scabies; Resident was left in soiled clothing for an extended period of time and Facility staff did not ensure the resident’s medical equipment was in working order.
The investigation included record review including, but not limited to medical records, progress notes from Care tech Home Care and interviews with pertinent parties. The investigation revealed the following:
Medical Records obtained from the home health provider document Resident #1 (R1) was determined to have a stage III Pressure injury in June of 2020, while living at Family Choice Senior Care 4.
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Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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 7
Control Number 22-AS-20200804151931
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: FAMILY CHOICE SENIOR CARE 4
FACILITY NUMBER: 306003385
VISIT DATE: 06/28/2021
NARRATIVE
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 Interviews conducted concluded that R1 began to receive home health care from Caretech Home Care on June 22, 2020 for an abscess wound at their armpit, scabies and a pressure injury at their coccyx.
Interviews conducted and progress notes from the home health agency revealed that on June 24, 2020 the wound was assessed to be a stage 3 pressure injury. A home health LVN noticed R1 was not on their air loss mattress. The LVN inquired about R1’s air loss mattress. Staff informed the LVN that R1 was moved to another room for isolation due to scabies. On July 28, 2020, the home health LVN observed and documented a new pressure injury to R1’s coccyx area. The LVN contacted the VA Hospital regarding the new pressure injury and reminded the facility caregiver that a mepilex dressing change should be completed 3 times a week and as needed. On July 31, 2020 the home health LVN documented and observed a Coccyx Deep Tissue Injury (DTI) in between the former coccyx wound and another coccyx wound. The DTI was described as purple and maroon with a bruise like appearance. The facility staff reported to the LVN, that the only thing they did different since the last LVN visit was trying to put R1 in a wheelchair. The LVN had previously recommended to avoid using a wheelchair until the injuries were healed. R1 was not supposed to be placed in a wheelchair due to their wound.
On August 3, 2020 a home health LVN observed R1’s mattress was turned off and asked facility staff why R1’s air loss mattress was off. Staff responded that they didn’t know why it was off. The LVN indicated R1’s diaper was soaked through to the bottom disposable pad, and when the diaper was opened it has a strong smell of ammonia. On August 12, 2020, the home health LVN report indicated R1’s coccyx pressure injuries as worsening with greenish spots. Discharge notes from Care tech Home Care concluded R1 was discharged from Caretech Home Care on August 14, 2020. Progress Notes from home health agency dated June 24, 2020 revealed the Home Health LVN spoke to the facility Administrator and inquired about the policy for pressure injury patients. The Administrator replied that the facility can’t retain a resident who has a pressure injury greater than stage 2. All stage 3 pressure injury or greater require the patient be sent to a Skilled Nursing Facility or hospital if the wound is not get better in a few weeks.

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SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 22-AS-20200804151931
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: FAMILY CHOICE SENIOR CARE 4
FACILITY NUMBER: 306003385
VISIT DATE: 06/28/2021
NARRATIVE
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Interviews concluded that R1’s air loss mattress was unavailable as required for R1. During an interview conducted on October 01, 2020, Licensee Representative Shazad Khan stated they asked the Executive Director about the bed issue and was told she did not know anything about it and found no documentation of the issue in the facility log or care notes. Five (5) of Five (5) Interviewees indicated that the required air loss mattress was removed from R1’s room for an unknown amount of time. R1 had been relocated to a different room twice due to remodeling work being done in the facility. Interviewees reported R1 went without using the air mattress. Although staff tried to mitigate R1’s pressure injury by turning the resident on their side and repositioning the resident. Interviews conducted concluded that the resident would resume laying flat on their back and that the required air loss mattress was not being provided to R1.
Licensee Representative Shazad Khan had the facility doctor assess all the residents in the facility due to the residents having rashes. The doctor decided to treat all residents for scabies out of precaution, despite the fact that none of the residents were ever medically tested or confirmed for scabies. One (1) of six (6) Interviewees stated R1, as well as the rest of the residents, had a rash but were never tested and verified as scabies. All residents were treated with permethrin cream, which is used to treat scabies.
There was not a request for an exception received by the Department in order to retain a resident with a prohibited health condition of unstageable pressure injuries nor was R1 observed to be receiving hospice care services. Licensee Shazad Khan did not report that he notified the home health nurse of the condition’s prohibited status.
Based on the preponderance of evidence gathered through multiple interviews and documents obtained; the allegations “Resident sustained multiple pressure injuries while in care,” “Facility staff did not keep facility free of scabies,” “Resident was left in soiled clothing for an extended period of time,” and “Facility staff did not ensure that resident’s medical equipment was in working order,” has been met. Therefore, the allegations listed above are deemed to be SUBSTANTIATED.
The facility is being cited per Title 22, Division 6 of the California Code of Regulations.
An exit interview was conducted with Licensee Shazad Khan on 6/28/2021 and on 6/29/2021 with Licensee Jack Carlino. A copy of this report, along with 9099-D, Appeal Rights, and the LIC 811, identifying confidential names were provided to Licensee Representative Shazad Khan and Jack Carlino. The report, along with all other documents listed above were sent via email and an electronic email read receipt confirms receiving of the report. Licensee Khan agrees to review the report and to send the signed report back to the LPA Quiroz via email.
***THIS IS AN AMENDED REPORT***
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
08/04/2020 and conducted by Evaluator Rosie Quiroz
COMPLAINT CONTROL NUMBER: 22-AS-20200804151931

FACILITY NAME:FAMILY CHOICE SENIOR CARE 4FACILITY NUMBER:
306003385
ADMINISTRATOR:VIRGILIO AGASFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:0CENSUS: 0DATE:
06/28/2021
UNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Shazad Khan, Licensee RepresentaiveTIME COMPLETED:
12:13 PM
ALLEGATION(S):
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-Facility is in disrepair, bathroom was not in working order
-Facility staff did not assist resident with bathing needs
INVESTIGATION FINDINGS:
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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz contacted Licensee Representative Shazad Khan and conducted a visit on this day for the purpose of delivering findings regarding the allegations listed above. This Complaint was investigated by Department.
It was alleged that Facility is in disrepair; Bathroom was not in working order; and that Facility staff did not assist resident with bathing needs. The investigation revealed the following:
Interviews were conducted with a total of 10 interviewees. Four (4) of 10 interviewees reported bathrooms in the facility were in working order. Five (5) of 10 interviewees reported the Facility was going through some remodeling but stated there was always a working bathroom available for residents and staff. Four (4) of 10 interviewees interviewed reported facility staff assisted resident with bathing needs. The facility showering schedule and resident’s needs and services plans could not be confirmed via documentation.
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Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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 7
Control Number 22-AS-20200804151931
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: FAMILY CHOICE SENIOR CARE 4
FACILITY NUMBER: 306003385
VISIT DATE: 06/28/2021
NARRATIVE
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During interviews, it was determined that the allegation could not be corroborated by evidence nor witnesses. Resident 1 (R1) passed away on January 06, 2021, therefore R1 was not able to be interviewed. Based on the preponderance of evidence gathered through multiple interviews; the allegations Facility is in disrepair; Bathroom was not in working order; and that Facility staff did not assist resident with bathing needs are deemed to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
An exit interview was conducted with Licensee Representative Shazad Khan via telephone. The report was sent via email and an electronic email read receipt confirms receiving of the report. Licensee Representative Khan agrees to review the report and to send the signed report back to the LPA Quiroz via email.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20200804151931
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: FAMILY CHOICE SENIOR CARE 4
FACILITY NUMBER: 306003385
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2021
Section Cited
CCR
87615(a)
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87615 (a) Prohibited Health Conditions: (a)(1) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 pressure injuries. This requirement is not being met as evidenced by; Continued...
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Facility has since undergone a change of ownership. Licensee is no longer operating facility.
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On 6/24/2021, R1 was diagnosed with a stage 3 pressure injury on 6/24/20 by a home health nurse. Administrator Csukardi did not contact the Department to obtain exception waiver and retained resident in the facility. This poses an immediate Health and Safety Risk to residents in care.
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Type A
06/28/2021
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by; on 08/03/2020 and 08/12/2020,
Continued...
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Facility has since undergone a change of ownership. Licensee is no longer operating facility.
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home health notes reported R1’s diaper being soaked through and smelling of a stong ammonia like smell. R1’s wound was reported to have worsened and having developed greenish spots. This poses an immediate Health Risk to residents 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20200804151931
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: FAMILY CHOICE SENIOR CARE 4
FACILITY NUMBER: 306003385
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2021
Section Cited
CCR
87465(a)
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87465 (a)Incidental Medical and Dental Care:(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(1) The licensee shall arrange, Contined...
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Facility has since undergone a change of ownership. Licensee is no longer operating facility.
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or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by; on 6/24/2020, 7/31/2020, and 8/3/2020 R1’s air mattress was turned off and not provided as required to R1. This poses an immediate risk to resident’s health.
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Type A
06/28/2021
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operations. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
Continued...
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Facility has since undergone a change of ownership. Licensee is no longer operating facility.


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 This requirement is not met as evidence by; Interviews conducted reported all residents in care were observed to have rashes and/or bumps. Residents were treated for scabies. This poses a potential health risk to residents in care.

THIS IS AN AMENDED 9099-D
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7