306004753-1-25-2023-22-AS-AORZ-CNLRAL-20230131115119

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004753
Report Date: 01/25/2023
Date Signed: 01/25/2023 11:36:49 AM

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
01/20/2023 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20230120164200

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: 45	DATE:	01/25/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Jesus Soto		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff unlawfully evicted a resident
Staff did not prevent other residents from occupying another resident's bed
Due to staff neglect, Resident sustained a fall while in care

INVESTIGATION FINDINGS:

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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 physician report and medication orders. Regarding the allegations that due to staff neglect, resident sustained a fall while in care, staff did not prevent other residents from occupying another resident's bed and staff unlawfully evicted a resident, the investigation revealed the following: On 01/20/2023, Administrator had a conversation with Resident 1's(R1) responsible party regarding escalating behaviors. Administrator advised facility was having difficulty handling resident and a private one on one caregiver would be needed. Administrator stated facility had been providing staff in the capacity of a one on one caregiver but now needed to be formalized with private pay. It was also discussed that the resident could be taken to the Veteran's ER for possible admit to Geri-Psych or work together for better placement. Responsible party CONTINUED ON LIC 9099C DATED 01/25/2022

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: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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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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
01/20/2023 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20230120164200

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: 45	DATE:	01/25/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Jesus Soto		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not properly administer medication to a resident while in care

INVESTIGATION FINDINGS:

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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 orders and medication administration record. R1 was prescribed Lorazepam 2MG (Ativan) as needed (PRN). Per medication administration record, R1 was given Lorazepam once on January 3, 2023 and four times in December. Lorazepam was discontinued on January 11, 2023. Resident did not receive the medication after the stop date nor on the date of R1's hospital send out, January 8, 2023. Therefore the allegation is deemed UNFOUNDED, meaning the allegation 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.

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: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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 3

Control Number 22-AS-20230120164200

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: 01/25/2023

NARRATIVE

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took the resident to the ER for evaluation. Resident is still admitted into facility and Administrator denies resident has discharged from the facility. Administrator denies giving an eviction notice verbally or otherwise and states the conversation was to come up with a plan for caring for the resident. Five out of five staff interviewed state resident's behaviors have escalated and resident attempts to hit other residents and staff even on medication adjustments. On 01/08/2023, R1 was observed coming into the facility from the courtyard with blood on the resident's head and a scrape on right shin. The incident was un-witnessed and facility staff do not know if resident fell or was having a behavior outside. R1 does not have a history of falls at the facility. Resident prefers to walk in the enclosed courtyard and staff state checking on the resident while walking outside. Resident was assessed and sent out to the hospital for evaluation for injury and severe agitation. Resident returned same day. Upon return to the facility, another resident was asleep in R1's bed. Sleeping resident was re-directed and linens changed per facility protocol. As the facility is designated memory care, residents frequently wander into other resident's rooms including R1. 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: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC9099 (FAS) - (06/04)

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