306003838-7-26-2023-22-AS-SSAS-CU89UF-20230729234039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003838
Report Date: 07/26/2023
Date Signed: 07/26/2023 04:26:13 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
07/18/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230718085922

FACILITY NAME:	MEISON LA PAZ IV ELDERLY CARE HOME		FACILITY NUMBER:	306003838
ADMINISTRATOR:	HERMELINDA/MIGUEL PEREZ		FACILITY TYPE:	740
ADDRESS:	25371 MAXIMUS		TELEPHONE:	(949) 472-4636
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	07/26/2023
		UNANNOUNCED	TIME BEGAN:	04:01 PM
MET WITH:			TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff handled residents in a rough manner.

Staff injured resident while in care.

Staff yell at residents in care.

Staff not meeting resident(s) needs.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering finding into the investigation of the allegations listed above. LPA was greeted and granted entry by caregiving staff after introducing himself, stating the purpose of the visit and listing the allegations. Administrator Hermelinda Perez was notified of the visit and presented the detailed findings via telephone.

On July 21, 2023, an initial complaint investigation visit was conducted at the facility. LPA accompanied by administrator toured the physical plant. LPA requested and obtained resident records for all residents currently admitted in addition to one resident that had been recently discharged from the facility. Staff records were additionally requested and reviewed. Four resident interviews and three staff interviews were conducted during the visit. Additional witness interviews were led as a follow-up after the visit.

CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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-20230718085922

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MEISON LA PAZ IV ELDERLY CARE HOME	FACILITY NUMBER: 306003838
	VISIT DATE: 07/26/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099 - Regarding the allegation that Staff handled residents in a rough manner, the following has been concluded: The evidence gathered based on interviews conducted with staff and residents as well as observation conducted during the facility visit was insufficient to establish a pattern or habits of rough handling. Four residents interviewed confirmed that they were being treated well. The account was corroborated by additional witness interviews. As a result, the allegation is Unsubstantiated, meaning that although the allegation may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violation occurred.

Regarding the allegation that Staff injured resident while in care, the following has been concluded: Resident R1 was alleged to have received injuries as a result of their treatment by facility staff. A review of the resident's records kept at the facility showed that the resident was seen at least twice a week by a hospice nurse for a full assessment following R1's admission into hospice on or around April 14, 2023. Twenty-three (23) reports were reviewed, with no mention of an injury caused by staff. Photographs of bruising on the resident's hands was provided but could not directly be linked to a known cause. An instance of a fall was mentioned, but did not appear to involve staff responsibility. Therefore the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violation occurred. A Technical Violation Advisory Note is however issued to the facility as the fall was not reported to the Department.

Regarding the allegation that Staff yell at residents in care, the following has been concluded: All residents present at the facility were interviewed and denied ever witnessing instances of staff yelling at themselves or other residents in care. Residents are however all diagnosed with varying levels of cognitive impairment making a definitive assessment difficult. Their account were corroborated by additional witness interviews by individuals with frequent knowledge of the facility. The allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violation occurred.

Regarding the allegation that Staff is not meeting residents' needs, the following has been concluded. Allegation was made in regard to resident R2 not receiving adequate assistance during meals to receive sufficient nutrition in regard to her needs.

CONTINUED ON LIC9099-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230718085922

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MEISON LA PAZ IV ELDERLY CARE HOME	FACILITY NUMBER: 306003838
	VISIT DATE: 07/26/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099-C

Resident R2 was interviewed at the facility and stated that she was receiving sufficient assistance and enough food according to her hunger levels. She was additionally observed asking staff about mealtime on multiple occasions by LPA during the visit, as well as receiving sufficient attention and nutrition during the lunch served in the presence of LPA. Additional witness W1 confirmed that she had observed multiple meals and corroborated the observation. The allegation is therefore also found to be Unsubstantiated, meaning that although the allegation may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

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