306003932-12-14-2022-22-AS-SSAS-CM6PCV-20221216101233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003932
Report Date: 12/14/2022
Date Signed: 12/14/2022 04:55:48 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
10/29/2021 and conducted by Evaluator Kathrina Chin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20211029143054

FACILITY NAME:	GOLDEN YEARS - VILLA GRANDE		FACILITY NUMBER:	306003932
ADMINISTRATOR:	MARY CHIERICHETTI		FACILITY TYPE:	740
ADDRESS:	4332 VILLA GRANDE DRIVE		TELEPHONE:	(714) 223-0994
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 6	DATE:	12/14/2022
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Rowena Bungay		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Resident sustained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kathrina Chin made an unannounced visit to deliver the findings on the above allegation. LPA discussed the purpose of the visit with Administrator, Mary Chierichetti over the telephone and met with Rowena Bungay, Caregiver. The following are the findings of the investigation which involved interviews and records review.

The investigation revealed that resident (R1) resided at the Golden Years - Villa Grande facility on December 4, 2020. Resident was on hospice care starting on December 04, 2020. R1 has been diagnosed with dementia and severe contractures.
On October 21, 2021, R1’s responsible party observed that R1 had a large bruise on her left shoulder and left breast area while visiting the facility. The Hospice Physician and Hospice Nurse were informed of the large bruise on the same day. (Continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

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-20211029143054

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: GOLDEN YEARS - VILLA GRANDE	FACILITY NUMBER: 306003932
	VISIT DATE: 12/14/2022

NARRATIVE

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On October 21, 2021, R1’s responsible party observed that R1 had a large bruise on her left shoulder and left breast area while visiting the facility. The Hospice Physician and Hospice Nurse were informed of the large bruise on the same day.

On October 21, 2021, the physician was made aware of the bruises, the physician immediately ordered x rays for R1. No fractures were found. The Hospice Physician asked if the responsible party would like to transport R1 to the hospital. R1’s responsible party declined for R1 to be transferred to a hospital. The Hospice Physician stated that there is no explanation as to what happened to R1 and how the bruise was sustained.

The Hospice Nurse was interviewed and she further explained that R1 had very frail skin and bruises easily. Resident would also hit herself. Resident has severe contractures. Also, it was difficult to sponge bathe or put on clothes on R1 because of severe contractures. The responsible party allowed for the shirt to be cut in the back so staff do not need to lift the arm so often. The Hospice Nurse stated that it was a bruise which cannot be explained as to what happened.

The day before on October 20, 2021, the hospice physician visited R1 at the facility and he stated that he saw no bruises on R1. Both the hospice doctor and hospice nurse stated that they did not observe any bruises on R1. R1’s responsible party stated that she also came to visit R1 on October 20, 2021. R1’s responsible party and the Hospice nurse visited the facility and a body check was completed and no bruises were observed.

LPA Chin interviewed R1’s responsible party and stated that she conducted regular body check for bruises on R1. R1’s responsible party stated that she allowed R1’s shirt to be cut open in the back so facility staff and hospice staff didn't have to be lift R1’s arms so often. The responsible party of R1 stated that she did not want to transport R1 to the hospital because of the bruise. X rays were completed on October 21, 2021 and there were no fractures.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20211029143054

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: GOLDEN YEARS - VILLA GRANDE	FACILITY NUMBER: 306003932
	VISIT DATE: 12/14/2022

NARRATIVE

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LPA, Kathrina Chin attempted to interview R1 but R1 was very weak and did not answer. R1 was sleeping when LPA entered the room. She opened her eyes and closed it immediately.

LPA interviewed three other staff members. S1, S2 and S3 denied that resident fell or was injured in anyway. All three staff members did not know how R1 sustained the large bruise.

Based on the information gathered during the investigation and review of all documents obtained, the following allegation: Resident sustained injuries while in care is deemed Unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of this report was provided during the visit to Administrator, Mary Chierichetti.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

LIC9099 (FAS) - (06/04)

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