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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003560
Report Date: 05/13/2021
Date Signed: 05/13/2021 05:32:58 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
03/12/2021 and conducted by Evaluator Michael Barrett
COMPLAINT CONTROL NUMBER: 22-AS-20210312152248
FACILITY NAME:GRANNY'S PLACE IVFACILITY NUMBER:
306003560
ADMINISTRATOR:SIMPSON, RONALDFACILITY TYPE:
740
ADDRESS:25665 SABINA AVENUETELEPHONE:
(949) 855-0120
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
05/13/2021
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Administrator (AD) Ron SimpsonTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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-Facility is not administering medications as prescribed.
-Facility is not providing enough staffing for bedridden residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Mike Barrett contacted the facility via telephone to deliver findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted virtually with Administrator (AD), Ron Simpson. The following are the findings of the investigation conducted by the LPA Barrett, which involved interviews, record review and site observations.
It was alleged that the facility is not administering medications as prescribed. LPA requested and reviewed medication and prescription orders for R1 and observed the following: Rx: 62026610, 1/21/2021 by Dr. Sarah Teymoorian, MD: Quetiapine to 100 mg; Rx: 62086362: 1/11/2021 by Dr. Sarah Teymoorian, Lactulose 30mL; Rx: 61907345, 1/15/2021 by Dr Sarah Teymoorian, Quetiapine 100mg: Rx: 91607346 8/26/2020 by Dr. Sarah Teymoorian, Gabapentin 600mg RxS19041628999240, 11/5/2020 by Dr. Sarah Teymoorian MD: Ensure 2-3 cans per day per patient request – okay to refuse if not hungry; 11/16/2020, Rx: 62024966 Levothyroxine 75mg tablet;
Continued on page 2.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael BarrettTELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
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 5
Control Number 22-AS-20210312152248
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: GRANNY'S PLACE IV
FACILITY NUMBER: 306003560
VISIT DATE: 05/13/2021
NARRATIVE
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Continued from page 1.

Rx: 62004597 by Dr. Sarah Teymoorian, Vraylar 3 mg 1 cap per day. Interviews conducted determined that there were discussions between R1’s representative, Licensee and Dr. Teymoorian, regarding medication administration for R1 either in food or with the Ensure however, no evidence of doctor’s order for the administration of the medications in food or Ensure for R1 was observed. LPA requested and reviewed prescription orders for R1 and observed that they were followed.

This agency has investigated the complaint alleging that the facility is not administering medications as prescribed. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened /or is without a reasonable basis.

It was alleged that the facility is not providing enough staffing for bedridden residents. This facility is licensed for 6 residents in care. LPA Barrett received and reviewed the facility’s LIC 500 (staff schedule), dated 4/12/2021, and observed that the facility scheduled 6 caregivers working in the facility; all caregivers are listed as live-in caregivers. The schedule shows that Staff #1 (S1) was scheduled Monday thru Wednesday and Saturday thru Sunday, Staff #2 (S2) was scheduled Monday thru Friday, Staff #3 (S3) was scheduled Thursday thru Friday and Staff #4 (S4) was scheduled Saturday and Sunday showing that there were two (2) caregivers scheduled to work in the facility at all times and was confirmed with payroll reports obtained from the facility.

This agency has investigated the complaint alleging that the facility is not providing enough staff staffing for bedridden residents. Based on observation, documents reviewed, and interviews conducted, it was determined that the facility was appropriately staffed for the residents in care, therefore the above allegation is deemed to be UNFOUNDED.

No citations were issued for these allegations.

An exit interview was conducted with Administrator Ron Simpson via telephone and a copy of this report was provided to Administrator Simpson for signatures via email.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael BarrettTELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
03/12/2021 and conducted by Evaluator Michael Barrett
COMPLAINT CONTROL NUMBER: 22-AS-20210312152248

FACILITY NAME:GRANNY'S PLACE IVFACILITY NUMBER:
306003560
ADMINISTRATOR:SIMPSON, RONALDFACILITY TYPE:
740
ADDRESS:25665 SABINA AVENUETELEPHONE:
(949) 855-0120
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
05/13/2021
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Administrator (AD) Ron SimpsonTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
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-Facility charged resident for providing overnight care that was not part of the admission agreement for the resident.
-Facility failed to report fall incident of resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Mike Barrett contacted the facility via telephone to deliver findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted virtually with Administrator (AD), Ron Simpson. The following are the findings of the investigation conducted by the LPA Barrett, which involved interviews, record review and site observations.

It was alleged that the facility charged resident for providing overnight care that was not part of the Admission Agreement for the resident. Resident #1 (R1) moved into the facility on November 12, 2019. It was reported that R1 was in need of nighttime care due to R1’s diagnosis of dementia, frequent nighttime assistance and was considered a fall risk. For this allegation, LPA Barrett requested and reviewed R1’s Preplacement Appraisal (LIC 603) dated November 12, 2019, Physician’s Report (LIC 602A) dated December 20, 2020, Appraisal/Needs and Services Plan (LIC 625) dated July 23, 2020 and Admissions Agreement.
Continued on page 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael BarrettTELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20210312152248
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: GRANNY'S PLACE IV
FACILITY NUMBER: 306003560
VISIT DATE: 05/13/2021
NARRATIVE
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Continued from page 1.

The Physician’s report stated that R1 had a primary diagnosis of dementia, paranoia and schizoaffective disorder and a secondary diagnosis of hypothyroidism and chronic pain. Review of the physician’s report, preplacement appraisal information and the appraisal/needs and services plan revealed the need for assistance with activities of daily living (ADL) and monitoring at night. Interviews conducted revealed that nighttime care for R1 was understood, agreed upon and instituted. LPA reviewed the Admissions Agreement that was signed into agreement on November 12, 2019 and observed that on page 2, section 11, to state: “Live-in day workers require un-interrupted sleep and overtime pay; therefore, *Awake night duty, when needed, is coordinated with Granny’s Place, and is contracted separately by the family directly with separate caregivers. Granny’s Place may assist in finding attendants. The current rate is about $120.00 per night”. California Code of Regulations, Section 87705(c)(4)(A), states: “In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.” It was documented that R1’s responsible party had made payments to the facility for the overnight care in the amounts of $1080.00 (check #4943) for November 2019 and $3720.00 (check #4947) for December 2019, as agreed upon in the signed, admission agreement, but ceased further payments due to belief that the nighttime care was considered a “basic service”. As per Health and Safety Code section 1569.312, basic services is defined as “…those services required to be provided by the facility in order to obtain and maintain a license and include, in such combinations as may meet the needs of the residents and be applicable to the type of facility to be operated, the following: safe and healthful living accommodations; personal assistance and care; observation and supervision; planned activities; food service; and arrangements for obtaining incidental medical and dental care.” It was determined that R1 was in need of nighttime care and was provided an awake caregiver for an extra fee as stated in the signed admission agreement.

This agency has investigated the complaint alleging that the facility charged resident for providing overnight care that was not part of the Admission Agreement. We have found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Continued on page 3.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael BarrettTELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 22-AS-20210312152248
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: GRANNY'S PLACE IV
FACILITY NUMBER: 306003560
VISIT DATE: 05/13/2021
NARRATIVE
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Continued from page 2.

It was alleged that the facility failed to report fall incident of resident. It was reported that R1 suffered a fall on December 18, 2020 in the facility. 911 was contacted and the resident was transported to Memorial Care Saddleback Medical Center and treated for lacerations to R1’s forehead and chin. Interviews and documents reviewed revealed that the R1’s responsible party was contacted and informed of the fall incident. On March 16, 2021, LPA conducted a virtual visit to the facility with AD Simpson and toured the facility. During this visit, LPA observed the incident report that was filled out for the incident as well as the cover sheet dated December 20, 2020. LPA requested and received a copy of the documents from the facility on 3/18/2021. LPA reviewed the CCLD logs of incidents reported from the facility and was not able to locate the record of the above-mentioned incident. In review of the facility incident log, LPA observed that the facility had an adequate reporting history and had not been cited for any failure to report unusual incidents. Interviews with the Licensee and with R1’s responsible party revealed that this incident was promptly reported to R1’s responsible party.

This agency has investigated the allegation that the facility failed to report fall incident of resident. Based on observation, interviews conducted, and records reviewed and although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed to be UNSUBSTANTIATED.

No citations were issued for this complaint.

An exit interview was conducted with Administrator Ron Simpson via telephone and a copy of this report was provided to Administrator Simpson for signatures via email.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael BarrettTELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5