306003955-10-28-2020-22-AS-SSAS-BV7MEH-20201109083245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003955
Report Date: 10/28/2020
Date Signed: 10/28/2020 12:21:28 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
04/16/2020 and conducted by Evaluator Albert Marin

COMPLAINT CONTROL NUMBER: 22-AS-20200416102005

FACILITY NAME:	ARBOR COVE		FACILITY NUMBER:	306003955
ADMINISTRATOR:	KATHLEEN TOOMEY SMITH		FACILITY TYPE:	740
ADDRESS:	25735 CERVANTES LANE		TELEPHONE:	(949) 872-6448
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	10/28/2020
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Administrator Kathleen Toomey Smith		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff failed to supervise resident that resulted to an injury that needed hospitalization.

INVESTIGATION FINDINGS:

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As precautionary measures during the Coronavirus 2019 pandemic, Licensing Program Analyst (LPA) Albert Marin conducted an unannounced tele visit to this facility. LPA met Administrator (AD) Kathleen Toomey Smith and stated the purpose of this video conference was to deliver the investigation findings for the complaint filed last April 16, 2020 against this facility

On allegation that staff failed to supervise resident resulting in injury requiring hospitalization the following are the findings: On April 14, 2020 about 2:30 PM, Resident 1 (R1) got out of facility and walked towards the east direction of the street. About 80 feet away from the facility driveway, R1 sustained a fall, and per medical records, lost consciousness for about 5 minutes. R1 was brought to the hospital after the incident. Facility was not aware that R1 got out of the facility unsupervised until Police came and informed the staff about the incident on R1. R1 was admitted in the hospital; and was discharged back to the facility the following day with the diagnosis of Rib Fracture. Thus, the allegation that staff failed to supervise resident resulting in injury requiring hospitalization is SUBSTANTIATED.
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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020

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-20200416102005

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: ARBOR COVE	FACILITY NUMBER: 306003955
	VISIT DATE: 10/28/2020

NARRATIVE

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Deficiencies were observed and citations were issued per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD Smith. LPA discussed the findings, citations and appeal rights; and read the report to AD. Copies of this report, 9099 Deficiency page, appeal rights, and copy of the cited regulations will be provided to AD via email. AD agreed to acknowledge receipt of the reports by responding to the email.

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SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20200416102005

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: ARBOR COVE	FACILITY NUMBER: 306003955
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/29/2020 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	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 was not met as evidenced by:	1 2 3 4 5 6 7	As plan of correction, Administrator stated that facility staff are routinely checking the residents in care. Immediate threat reduced. Facility will regularly monitor residents for any change of behavior and will refer to physician and responsible party. (continuation below)
	8 9 10 11 12 13 14	Based on the investigation, the facility missed to provide adequate supervision to the resident. Facility did not recognize that Resident had gone out of the facility unassisted until the police came in to inform the facility. This posed immediate threat to the safety of resident in care.	8 9 10 11 12 13 14	( LPA Issued assessment of immediate civil penalty for absence of supervision) LPA provided copy of the section cited for reference. *** This copy is an amended report.
Type B 10/29/2020 Section Cited CCR 87705(c)(5)	1 2 3 4 5 6 7	Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:... Each resident with dementia shall have an annual medical assessment ... .This requirement was not met as evidenced by:	1 2 3 4 5 6 7	As plan of correction, Administrator stated that she will review the physician's report of residents and will get an update annual report for residents diagnosed with dementia or neuro-cognitive disorder. Updated physician's report for Resident 1 was provided during the course of investigation. Deficiency cleared.
	8 9 10 11 12 13 14	Based on the investigation, the facility missed to update the annual medical assessment ... done at least annually. The Physician's report was dated 9/11/2018. This posed potential	8 9 10 11 12 13 14	LPA provided copy of the section cited for reference. *** This copy is an amended report.

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: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020

LIC9099 (FAS) - (06/04)

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