306004761-10-12-2023-22-AS-SSAS-CWL2N7-20231013173216

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004761
Report Date: 09/21/2023
Date Signed: 10/12/2023 11:22:51 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
07/30/2020 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200730172918

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: 69	DATE:	09/21/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Lupe Jaime, Purchasing Director/Housekeeping Supervisor		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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-Lack of supervision resulting in resident suffering multiple falls.

-Staff did not see medical attention in a timely manner.

-Staff did not recognize a change in resident's condition.

INVESTIGATION FINDINGS:

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This unannounced visit conducted by Ruth Martinez, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above. LPA arrived at facility was greeted by staff and granted entry. LPA met with Lupe Jaime, Purchasing Director/Housekeeping Supervisor and explained the nature of the visit.

During the course of this investigation LPA conducted interviews with staff, a review of resident records was completed, and copy of pertinent documents obtained.
It is alleged that there is lack of supervision resulting in resident suffering multiple falls. Based on records review resident (R1) slide down from the recliner on July 29, 2020 and R1 stated there was no pain. Staff state there were in injuries and R1 indicated there was no pain or discomfort. Interview with staff indicated that R1 was checked twice an hour due to fall risk and monitored. Records review revealed that an

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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-20200730172918

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAMBRIDGE COURT	FACILITY NUMBER: 306004761
	VISIT DATE: 09/21/2023

NARRATIVE

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evening shift wellness check waiver that was signed to decline the service by R1’s responsible party.

It is alleged that staff did not see medical attention in a timely manner. R1 had two incidents of sliding down the recliner. Staff evaluated resident and did not observe any injuries. R1 stated they had no pain or discomfort. Facility staff notified the responsible party, as a result of the notification R1’s responsible party decided to take R1 for evaluation. Interview revealed that facility staff rendered immediate first aid to R1 and evaluated for any injuries.

It is alleged that staff did not recognize a change in the residents’ condition. Records review revealed that care plan outlines services provided included: reminders to socialize and watch for signs of fatigue, watch for signs of increasing emotional distress, and monitor resident to minimize fall risk/changes of behavior. LIC802 Physicians report indicates R1 able to feed self. Interview revealed that R1 was independent and weight loss management was not on the care plan. The interview revealed that facility staff do not do weigh in to residents.

Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, these allegations are deemed Unsubstantiated.

An exit interview was conducted with facility representative and a copy of this LIC9099 report was left at facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

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