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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004761
Report Date: 12/11/2023
Date Signed: 12/11/2023 04:52:26 PM

Substantiated


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
10/10/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231010130615
FACILITY NAME:CAMBRIDGE COURTFACILITY NUMBER:
306004761
ADMINISTRATOR:LAUREN CHONFACILITY TYPE:
740
ADDRESS:1621 COMMONWEALTH AVENUE, EASTTELEPHONE:
(714) 992-1750
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:99CENSUS: 75DATE:
12/11/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lauren Chon, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
3
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5
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7
8
9
Staff violated resident's personal rights

Staff isolated resident while in care

Facility is in disrepair

Facility is unsanitary
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 allegations listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit.

An initial complaint investigation was conducted on October 13, 2023. LPA requested and obtained the facility's employee roster and resident census. Resident records for 4 residents were requested and obtained. LPA accompanied by facility staff toured the physical plant of the facility. Two staff interviews were conducted along with two resident interviews. Additional video evidence was provided and reviewed over the course of the investigation.

During the present follow-up, additional resident and staff interviews were conducted by LPA prior to findings being delivered.
CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
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 6
Control Number 22-AS-20231010130615
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: 12/11/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099
Regarding the allegation that Staff violated resident's personal rights, the following has been concluded: Based on records and evidence reviewed, observation conducted at the facility and interviews conducted, it is determined that on multiple occasions, facility staff passively or actively disregarded the resident's expressed wishes and either continued providing care without taking the request into account or acknowledging it. Resident R1's physician report on file along with multiple appraisals indicate that R1 does not have dementia and is able to express their needs and wishes, which were then ignored by facility staff. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type A deficiency is cited on the attached form LIC9099-D.

Regarding the allegation that Staff isolated resident while in care, the following has been concluded: Based on interviews conducted and evidence reviewed, it was confirmed that on multiple instances, facility staff locked the door to R1's unit in the evening despite requests made verbally to leave the door unlocked. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type A deficiency is cited on the attached form LIC9099-D.

Regarding the allegation that Facility is in disrepair, the following has been concluded: Based on facility visit and interviews conducted, it was determined that following a technical incident, the facility's call system was left non-operational during an entire week-end, with no alternative means of contacting staff to request assistance or care being provided. At the time of the initial visit, visual alerts were observed to be operating, but sound alerts and doorbell rings were still not working. Therefore the allegation is Substantiated, meaning that the preponderance of evidence standard has been met. A Type B deficiency is cited on the attached form LIC9099-D.

Regarding the allegation that Facility is unsanitary, the following has been concluded: Based on evidence submitted and interviews conducted, facility staff was noted to not be observing basic infection prevention measures and were confirmed to be handling food or drinks with the same gloves that they had conducted toileting and handling of incontinence items with, thus not meeting the standards of sanitation required by Title 22 regulations. The allegation is thus found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type B deficiency is cited on the attached form LIC9099-D.

An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
10/10/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231010130615

FACILITY NAME:CAMBRIDGE COURTFACILITY NUMBER:
306004761
ADMINISTRATOR:LAUREN CHONFACILITY TYPE:
740
ADDRESS:1621 COMMONWEALTH AVENUE, EASTTELEPHONE:
(714) 992-1750
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:99CENSUS: 75DATE:
12/11/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lauren Chon, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident doesn't feel safe at facility

Staff did not treat resident with dignity and respect

Staff left resident unattended in feces for an extended period

Staff did not meet resident's needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following on the investigation of the allegations listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit.

An initial complaint investigation was conducted on October 13, 2023. LPA requested and obtained the facility's employee roster and resident census. Resident records for 4 residents were requested and obtained. LPA accompanied by facility staff toured the physical plant of the facility. Two staff interviews were conducted along with two resident interviews. Additional video evidence was provided and reviewed over the course of the investigation.

During the present follow-up, additional resident and staff interviews were conducted by LPA prior to findings being delivered.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
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 6
Control Number 22-AS-20231010130615
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: 12/11/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099-A
Regarding the allegation that Resident doesn't feel safe at facility, the following has been concluded: Based on interviews conducted, records reviews and tour of the facility's physical plant, no items of non-compliance putting the resident's safety into jeopardy could be identified. After a suspicion of electrical issues was expressed by R1's family, facility maintenance staff along with Fire Marshall staff inspected the facility without finding any dysfunction needing to be addressed. As a result, the allegation is found to be Unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

Regarding the allegation that Staff left resident unattended in feces for an extended period, the following has been concluded: According to video evidence obtained during the investigation, there was at least one instance of having diarrhea during which R1 expressed difficulty in obtaining assistance. The evidence provided did not sufficiently establish the exact time frame during which the resident was left unattended that night beyond the four minutes captured by video. As a result, the allegation is found to be Unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

Regarding the allegation that Staff did not treat resident with dignity and respect, the following has been concluded: Based on the review of records and interviews conducted, a consistent pattern of not allowing the resident with the dignity and respect required by facility staff could not be evidenced. As a result, the allegation is found to be Unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

Regarding the allegation that Staff did not meet resident's needs, the following has been concluded: Facility staff states that they notified R1's conservator and relatives that the resident had reached a level of care incompatible with their remaining at the facility, however due to the duration of the resident's admission at the facility, facility staff eventually agreed to let the resident remain admitted there and to provide the required care and supervision there. Despite indications that care for R1 was complex, there is insufficient evidence to demonstrate that the facility did not meet the resident's needs before their relocation to a different board and care. Thus, the allegation is found to be Unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20231010130615
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2023
Section Cited
CCR
87468.1(a)(3)
1
2
3
4
5
6
7
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (...) (3) To be free from (...) other actions of a punitive nature, such as (...) interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee to provide a statement indicating its plan to retrain all staff members on the applicable rights of residents in care by the plan of corrections due date.
8
9
10
11
12
13
14
Based on evidence reviewed and interviews conducted, there were two documented instances of staff disregarding verbal requests to go back to bed. This constitutes an immediate risk to the health, safety or personal rights of residents in care.
8
9
10
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14
Type A
12/12/2023
Section Cited
CCR
87468.1(a)(6)
1
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7
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (...) (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by:
1
2
3
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5
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7
Licensee to provide a statement indicating its plan to retrain all staff members on the applicable rights of residents in care and measures to ensure no resident is locked without their consent by the plan of corrections due date.
8
9
10
11
12
13
14
Based on interviews conducted, it was determined that facility staff was locking R1's room at night regardless of the resident's agreement or not. This constitutes an immediate risk to the health, safety or personal rights of residents in care.
8
9
10
11
12
13
14
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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20231010130615
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2023
Section Cited
CCR
87303(i)(1)
1
2
3
4
5
6
7
(1) All facilities licensed for 16 or more (...) shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff (...)
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The call system was verified to be fully operational during the follow-up investigation visit and the deficiency was cleared at that time.
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(C) Identify the specific resident living unit. This requirement is not met as evidenced by: Based on interviews conducted, the facility spend several days with a completely inoperant call system in October 2023. This constitutes a potential risk to the health, safety and personal rights of residents in care
8
9
10
11
12
13
14
Type B
01/10/2024
Section Cited
CCR
87470(a)(1)
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2
3
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5
6
7
87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows: (1) All staff and volunteers shall perform hand hygiene.This requirement is not met as evidenced by: Based on evidence reviewed,
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2
3
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5
6
7
Licensee to provide a statement indicating its plan to retrain all staff members on adequate hand hygiene by the plan of corrections due date.
8
9
10
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13
14
it was determined that adequate hand hygiene measures had not been followed after staff handled bodily fluids and/or provided incontinence care to a resident with a urostomy. This constitutes a potential risk to the health, safety and personal rights of residents in care,
8
9
10
11
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13
14
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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6