306004761-3-16-2023-22-AS-SSAS-CQ8VTE-20230324164257

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004761
Report Date: 03/16/2023
Date Signed: 03/16/2023 02:57:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
01/17/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230117120805

FACILITY NAME:	CAMBRIDGE COURT		FACILITY NUMBER:	306004761
ADMINISTRATOR:	LAUREN CHON		FACILITY TYPE:	740
ADDRESS:	1621 COMMONWEALTH AVENUE, EAST		TELEPHONE:	(714) 992-1750
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY:	99	CENSUS:	DATE:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Lauren Chon, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff failed to meet resident's needs

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegation listed above and deliver findings to the licensee. LPA was greeted and granted entry by Lauren Chon, Administrator, after explaining the purpose of the visit and stating the allegation.

LPA requested, obtained and reviewed the facility's current census with room assignments, the facility roster and contact information for all staff members along with resident records for five residents. A copy of individual staff clock-ins from the period of January 1 until January 15, 2023 was also provided along with the weekly schedules for the weeks of January 8 until January 14 as well as January 15 until January 21, 2023. LPA additionally conducted interviews with four staff members. Medical records for resident R1 were additionally requested from St. Jude via subpoena and received on March 16, 2023.

CONTINUED ON FORM LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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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Control Number 22-AS-20230117120805

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAMBRIDGE COURT	FACILITY NUMBER: 306004761
	VISIT DATE: 03/16/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099

Submitted records were reviewed and additional interviews conducted.

During the March 17, 2023 follow up visit, LPA conducted a follow-up interview with administrator.

Regarding the allegation that Facility staff failed to meet resident's needs, the following has been concluded:

Resident R1 was admitted to the facility on December 10, 2022. Initially upon admission, the resident's health condition was noted to be good and she would attend meals in the dining room. However, based on interviews conducted the resident's condition was stated to decline rapidly. Shift notes for the month of January however only make one mention of the resident and do not include her transfer to the hospital on January 15, 2023.

Upon admission at St. Jude Emergency Department, resident was observed to be severely dehydrated and had sustained Acute Kidney Injury caused by the prolonged diarrhea suffered. Based on interviews conducted, the resident's family had requested to be notified of any continued or worsening condition. Interviews also determined that facility procedure is for caregiving staff to notify Med Tech or Med Tech supervisor for them to get in touch with the family, which does not appear to have been conducted until January 15, 2023. Facility did not take the initiative to get resident assessed by paramedics until requested by family to do so on that day

Therefore, based on interviews conducted and a review of records provided the allegation that Facility staff failed to meet resident's needs is deemed to be Substantiated, meaning that the preponderance of evidence standard has been met.

One deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted and a copy of this report was provided and left at facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230117120805

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAMBRIDGE COURT	FACILITY NUMBER: 306004761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/17/2023 Section Cited CCR 87464(f)	1 2 3 4 5 6 7	87464(f): "Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code [meaning] the facility assumes responsibility for (...) ongoing assistance with activities of daily living without which the	1 2 3 4 5 6 7	Licensee to assess reporting procedure and shift incident logs to ensure proper response is provided to residents' needs. Facility to provide in-service training and certify assessment has been conducted.
	8 9 10 11 12 13 14	resident’s physical health (...) would be endangered. This requirement is not met as evidenced by: Based on interviews and records reviewed, facility failed to provide adequate supervision. This posed an immediate risk to the health and safety of individuals in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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