306004218-7-12-2021-22-AS-AORZ-C55TZF-20210721151017

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004218
Report Date: 07/12/2021
Date Signed: 07/12/2021 04:01:49 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
05/08/2020 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200508102458

FACILITY NAME:	OC KAIGO HOMES		FACILITY NUMBER:	306004218
ADMINISTRATOR:	KAZUHIRO KOTANI		FACILITY TYPE:	740
ADDRESS:	22322 SAVONA		TELEPHONE:	(408) 393-3337
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS: 5	DATE:	07/12/2021
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Kazuhiro Kotani		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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-Resident sustained major injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to deliver findings for the investigation into the above identified complaint allegation. LPA spoke with Administrator and explained the purpose of the visit.

The investigation was conducted by the Department. Findings are based upon this investigation which included file review, interviews with the following: multiple staff, residents and witnesses, medical records from Saddleback Valley Radiology and medical records from Hoag Memorial Hospice.

It is alleged that resident sustained major injuries while in care. The investigation revealed the following: Resident 1’s (R1) needs and appraisal dated 04/20/2020 states R1 is a fall risk, as R1 becomes restless and will roll from side to side when using their wheelchair and while in bed. The facility implemented measures to

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

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-20200508102458

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: OC KAIGO HOMES	FACILITY NUMBER: 306004218
	VISIT DATE: 07/12/2021

NARRATIVE

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assist in mitigating any falls and injuries, such as moving R1’s bed to the opposite wall near the door and placing the recliner where it is visible to staff from the doorway. Bed rails are always to be up when R1 is in bed per physician orders with pillows placed between bed rail and wall. A fall mat was also placed at the side of R1’s bed when R1 is in bed. Staff are able to observe R1 multiple times hourly and do safety checks at least every 30-40 minutes to ensure R1’s comfort and safety. Interviews conducted with witness indicated that R1’s family was told to hire a nighttime care provider as R1 needs special observation/night supervision due to their confusion, forgetfulness and rolling in bed. Family hired two caregivers to watch over R1 from 7:00pm to 6:00am. R1’s physician’s report dated 4/09/2019 indicated that R1 was diagnosed with dementia (sundowner) and gets agitated easily, flailing their arms at staff sometimes when being assisted. Medical records reveal R1’s bones are osteoporotic, causing R1’s bones to become weak and brittle. It was reported by staff that R1 would throw their legs into the safety rail of the bed. However, interviews conducted with 4 of 4 staff denied R1 had any falls at the facility. Although the mechanism that caused the injuries remains unknown, there is not a preponderance of evidence to prove that the allegation of neglect/lack of supervision occurred as reported. Therefore, it cannot be proven or disproved with certainty that there was a neglect/lack of supervision with the care provided by the facility staff.

Based on the information gathered during the investigation, interviews and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

A copy of this report is being reviewed with Administrator and a copy of this LIC9099 furnished to the facility.

SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

LIC9099 (FAS) - (06/04)

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