306004753-5-25-2022-22-AS-AORZ-CETVKK-20220527163029

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004753
Report Date: 05/25/2022
Date Signed: 05/25/2022 01:40:49 PM

Unfounded

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
04/26/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220426131332

FACILITY NAME:	CRESCENT LANDING AT GARDEN GROVE MEMORY CARE		FACILITY NUMBER:	306004753
ADMINISTRATOR:	JESUS SOTO FLORES		FACILITY TYPE:	740
ADDRESS:	11848 VALLEY VIEW STREET		TELEPHONE:	(714) 895-9898
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92845
CAPACITY:	72	CENSUS: 28	DATE:	05/25/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jesus Soto		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained unexplained bruising while in care.
Medical attention was not sought for resident in a timely manner.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of initiating an investigation on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as medication records and physician report. Regarding the allegations that resident sustained unexplained bruising while in care and medical attention was not sought for resident in a timely manner the investigation revealed the following: Per physician report dated 01/05/2022, Resident 1 (R1) is diagnosed with Parkinson's Dementia. Resident is noted to have agitation and hallucinations. Two out of two witnesses interviewed and three out of three staff interviewed state resident has behaviors which include hitting the resident or objects causing bruising. Facility states resident is only left alone while sleeping and is constantly monitored. All interviewed state there is no abuse or neglect occurring with this resident. Resident has been struggling with a rash on the resident's body. All parties interviewed state the facility sought immediate attention for the rash CONTINUED ON LIC 9099C DATED 05/25/2022

Unfounded

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: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 22-AS-20220426131332

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: CRESCENT LANDING AT GARDEN GROVE MEMORY CARE	FACILITY NUMBER: 306004753
	VISIT DATE: 05/25/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

and has been working with medical providers regarding the rash. R1 had a referral for a specialist after the medical provider was having difficulty treating the rash. R1 had a virtual dermatology appointment scheduled for the rash but was missed due to technology issues. Since the missed appointment, R1 had a make-up appointment with the dermatologist and the rash was addressed. Medication orders indicate the facility had been following medication orders to treat the rash. Therefore the allegations are deemed UNFOUNDED, meaning the allegations are was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
04/26/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220426131332

FACILITY NAME:	CRESCENT LANDING AT GARDEN GROVE MEMORY CARE		FACILITY NUMBER:	306004753
ADMINISTRATOR:	JESUS SOTO FLORES		FACILITY TYPE:	740
ADDRESS:	11848 VALLEY VIEW STREET		TELEPHONE:	(714) 895-9898
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92845
CAPACITY:	72	CENSUS:	DATE:	05/25/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:			TIME COMPLETED:	10:40 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident developed skin rash(es) while in care.
Medication was not adminstered to resident according to their physician's orders.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of initiating an investigation on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as medication records and physician report. Regarding the allegations that medication was not adminstered to resident according to their physician's orders and resident developed skin rash(es) while in care, the investigation revealed the following: R1 had a medication order for Miralax, generic Polyethylene Glycol, as a PRN order. Order stated to take "As needed." Facility states resident was not in need of it and was taking Senna PRN and Docusate Sodium daily. Medication records indicate resident was receiving the Docusate Sodium, Senna, and two instances of the Miralax. Resident had a skin rash suspected by physician to be Scabies. Two witnesses and three staff confirm R1 was seen by a physician immediately for the skin condition. Facility stated there was no Scabies outbreak at the facility. Per Administrator, a subsequent appointment with CONT ON LIC 9099C DATED 05/25/2022

Unsubstantiated

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: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20220426131332

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: CRESCENT LANDING AT GARDEN GROVE MEMORY CARE	FACILITY NUMBER: 306004753
	VISIT DATE: 05/25/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

a dermatologist revealed the skin condition was not scabies. Per medication orders, R1 was being treated for the rash with various creams. LPA is unable to corroborate the allegations due to conflicting information. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with and a copy of this report was provided to facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4