306004308-10-25-2022-22-AS-AORZ-CKZ2RC-20221108163718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004308
Report Date: 10/25/2022
Date Signed: 10/25/2022 02:03:21 PM

Substantiated

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
10/06/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20211006161426

FACILITY NAME:	HOLLYBROOK SENIOR LIVING OF ORANGE		FACILITY NUMBER:	306004308
ADMINISTRATOR:	AMANDA HEMMINGER		FACILITY TYPE:	740
ADDRESS:	2025 N. BUSH STREET		TELEPHONE:	(714) 541-3357
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92706
CAPACITY:	120	CENSUS: 42	DATE:	10/25/2022
		UNANNOUNCED	TIME BEGAN:	12:16 PM
MET WITH:	Kristine Juarez and Alma Espinal		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Resident sustained a fall and injury while under care of facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to gather information regarding the above allegation. LPA was greeted and granted entry into the facility by Licensee Kristine Juarez and Alma Espinal explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff, resident and witness as well as reviewed and obtained pertinent documentation such as facility notes and physician report. Regarding the allegation that resident sustained a fall and injury while under care of facility, the investigation revealed the following: Resident 1 (R1) sustained a fall at the facility and was transferred to the hospital. Resident was diagnosed with urinary tract infection, left front side hematoma, and a compression fracture to the resident's T2, T3, and T12 vertebrae. Per Administrator at time of complaint, R1 was recovering from dental surgery at the time of the fall and had been seen actively trying to get out of bed when the resident fell. The resident was on pain medication at time of fall. Administrator stated that R1 was on frequent checks but facility does not have documentation of checks. It was reported to witness by family that R1 had prior falls in the facility. Per facility assessment dated 03/13/2021, R1 has a history of falls CONTINUED ON LIC 9099C DATED 10/25/2022.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

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-20211006161426

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: HOLLYBROOK SENIOR LIVING OF ORANGE	FACILITY NUMBER: 306004308
	VISIT DATE: 10/25/2022

NARRATIVE

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and required a fall management program. Facility was unable to provide fall management protocol other than frequent checks. Facility has changed ownership since time of complaint and has all new staff employed thus LPA unable to interview additional staff regarding the allegation. The preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8). Exit interview conducted and a copy of this report was left at the facility as well as appeal rights.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20211006161426

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: HOLLYBROOK SENIOR LIVING OF ORANGE	FACILITY NUMBER: 306004308
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/26/2022 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 is not being met as evidenced by:	1 2 3 4 5 6 7	Licensee to provide an outline on how to prevent falls when a resident poses a fall risk and forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record review and interviews conducted, Licensee failed to ensure care and supervision was provided to R1. R1 fell while recovering from dental surgery. Per facility documentation, R1 was a fall risk and required a fall prevention plan. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
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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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC9099 (FAS) - (06/04)

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