306004718-6-28-2021-22-AS-SSAS-C4K6BE-20210702203947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004718
Report Date: 06/28/2021
Date Signed: 06/28/2021 04:06:07 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
02/11/2021 and conducted by Evaluator Kathrina Chin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210211162053

FACILITY NAME:	GROVES OF TUSTIN, THE		FACILITY NUMBER:	306004718
ADMINISTRATOR:	LIANA FOOTE		FACILITY TYPE:	740
ADDRESS:	1262 BRYAN AVE		TELEPHONE:	(714) 730-5009
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	100	CENSUS: 82	DATE:	06/28/2021
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Liana Foote, Executive Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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1) Resident was neglected and lacked appropriate care and supervision resulting in falls and sustaining multiple injuries.

2) Facility staff failed to seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kathrina Chin made a visit by telephone-video via FaceTime to the facility for the purpose of presenting the findings of the complaint investigation. LPA discussed the findings with Liana Foote, Executive Director. The investigation consisted of interviews with the facility staff, Administrator and witnesses as well as documentation. The following was determined:

On February 9, 2021, R1 was leaving his room when he encountered staff 1 who was coming to check on him. R1 opened his front door and stumbled forward with his walker. S1 caught R1 so he could regain his balance. R1 did not fall to the floor. When R1 stumbled forward, he struck his right leg on his walker causing a laceration on his calf.

S1 contacted the Medication Technician on duty who assessed R1's injury and immediately called 911 against R1's wishes. The Paramedics arrived at the facility and recommended R1 be transported to the hospital for further care. (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: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

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-20210211162053

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: GROVES OF TUSTIN, THE	FACILITY NUMBER: 306004718
	VISIT DATE: 06/28/2021

NARRATIVE

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R1 refused to be transported and signed a waiver of refusal. The Paramedics treated R1's wound and recommended for R1 to make an appointment with his physician.

The next day, February 10, 2021, R1 was showing signs of weakness. R1 was hugging his girlfriend, Resident 2(R2) when they both fell to the ground. This was witnessed by Staff 3. Both the staff member and R2 assisted R1 to the ground and they did not hit the floor. The facility called 911 emergency personnel and R1 was transported to the hospital for evaluation. During the visit, R1 was treated for his right calf laceration and it was discovered that he had fractured ribs.

According to staff, there were no witnessed falls or accidents that would have caused R1's rib injuries. During the incidents of February 9, 2021 and February 10, 2021, R1 had no complaints of pain in his side, ribs or any shortness of breath. R1 was interviewed and he stated that he had no pain and he was unaware that he had fractured ribs.

According to the medical records, R1 suffered rib fractures during a fall in August of 2019. The mechanism of R1's current rib injuries are unknown and it is unclear whether the injuries are new or from his injury in 2019.

Although the allegations may have happened or are 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 with Liana Foote, Executive Director and a copy of this report was provided via email.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC9099 (FAS) - (06/04)

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