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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004772
Report Date: 02/03/2023
Date Signed: 02/03/2023 12:11:53 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
11/03/2021 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20211103112454
FACILITY NAME:RDB GUEST HOMEFACILITY NUMBER:
306004772
ADMINISTRATOR:REGIE D. BANGGALATFACILITY TYPE:
740
ADDRESS:612 BRONWYN DRIVETELEPHONE:
(714) 827-5538
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:0CENSUS: 0DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Vanessa Batara, House ManagerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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3) Resident sustained injury while in care.
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 delivering findings into the investigation of the allegations listed above. LPA Saborit-Guasch met Vanessa Batara, House Manager and was granted entry after explaining the purpose of the visit.

On November 10, 2021, LPA, Kathrina Chin conducted an unannounced visit for the purpose of investigating the above allegations. During the investigation, the Department interviewed staff, witnesses as well as reviewed and obtained pertinent records. A Police Report from Anaheim Police Department, photographs and video were all reviewed.

The investigation revealed that resident 1 (R1) resided at the RDB Guest Home previously located in 612 Bronwyn Drive Anaheim 92804 facility from October 16, 2021 to November 9, 2021.

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: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
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 5
Control Number 22-AS-20211103112454
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: RDB GUEST HOME
FACILITY NUMBER: 306004772
VISIT DATE: 02/03/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099

The Physician’s Report dated October 14, 2021 indicates R1 has a Dementia diagnosis. The physician reports indicates that R1 has dementia and is confused, displays inappropriate behavior, wandering behavior, aggressive behavior and sundowning behavior. Resident has a secondary diagnosis of Schizophrenia.

On October 21, 2021, R1 fell and hit her face into the sliding glass door closet located in the R1’s bedroom whom she shared it with another resident. R1 sustained redness on her nose and hands according to the R1’s responsible party. On 11/3/2021, R1 sustained redness on her right cheek due to wandering behavior or unwitnessed fall. The facility submitted a report regarding this incident. The facility staff informed R1’s responsible party regarding the redness on the right cheek and the cause of the injury on right cheek is unknown. Staff 1 stated to R1’s family that R1 sustained the right cheek injury due to R1 holding her face while she sleeps. When S1 was interviewed, R1 sustained large bump on right cheek due to the glass closet door in R1’s room. The facility Administrator indicated that it was an unwitnessed incident and how R1 sustained the bump on the right cheek is unknown. The police officer also observed swelling below the right eye, and redness on the nose.

Based on the information gathered during the investigation and review of all documents obtained, the following allegation is substantiated: Resident sustained injury while in care.

Based on LPA's observations and conducted interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

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

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

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20211103112454
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: RDB GUEST HOME
FACILITY NUMBER: 306004772
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2023
Section Cited
CCR
87464(f)(1)
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Section 87464 (f)(1) Basic Services-Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code (...) means the facility assumes responsibility for (...) ongoing assistance (...) without which the resident's (.....) safety (...) would be endangered.
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Facility closed, no POC in place
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This requirement was not met as evidenced by: On 10/21/21, R1 sustained redness on nose and hands from an unwitnessed fall. On 11/3/21, R1 sustained injuries on her right cheek from unwitnessed incident. This poses an immediate health and safety risk to resident
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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: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/03/2021 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20211103112454

FACILITY NAME:RDB GUEST HOMEFACILITY NUMBER:
306004772
ADMINISTRATOR:REGIE D. BANGGALATFACILITY TYPE:
740
ADDRESS:612 BRONWYN DRIVETELEPHONE:
(714) 827-5538
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:0CENSUS: 0DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Vanessa Batara, House ManagerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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1) Resident dispensed a medication not prescribed by physician.
2) Resident not administered medication as prescribed by physician.
(...)
4) Staff physically abused resident
5) Staff handles resident in a rough manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of delivering the findings on a complaint investigation. LPA Saborit-Guasch met Vanessa Batara, House Manager and was granted entry.

During the investigation of the above allegations, staff, witnesses were interviewed and pertinent records were reviewed. A Police Report from Anaheim Police Department was reviewed along with photographs and a video.

The investigation revealed that resident 1 (R1) resided at the RDB Guest Home previously located in 612 Bronwyn Drive Anaheim 92804 facility from October 16, 2021 to November 9, 2021. Resident had dementia per the Physician’s Report dated October 14, 2021.

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: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20211103112454
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: RDB GUEST HOME
FACILITY NUMBER: 306004772
VISIT DATE: 02/03/2023
NARRATIVE
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The physician reports indicated that R1 has dementia and is confused, displays inappropriate behavior, wandering behavior, aggressive behavior and sundowning behavior. Resident has a secondary diagnosis of Schizophrenia.

It was alleged that residents are being given the medication Ativan in order for R1 to sleep all the time. The medication is supposedly kept in a guest bathroom cabinet. LPA searched in all the bathroom cabinets and did not see any medications. Staff S1 and Staff S2 both stated that R1 does not have Ativan in her medication list. S1 and S2 both denied that R1 is being given the medication Ativan. S1 and S2 stated that they give R1’s medications as prescribed by her physician.

It was also alleged that facility staff may not be giving R1’s medications as prescribed by her physician. It may be the reason the resident appears to be sedated. LPA reviewed R1’s centrally stored medication list. Resident is receiving Seroquel, Memantine, and Citalopram. On October 28, 2021, Depakote and Gabapentin was stopped and Vitamin D3 was ordered to start.

It was alleged that Staff S1 slapped resident 1. Staff S1 denied slapping R1. The facility Administrator stated that S1 is patient with the residents and is a good worker. LPA interviewed R2 and R2 stated that S1 is a good caregiver and he has never observed S1 to be slapping any resident or be aggressive to R1. R2 stated that R1 is very confused and had wandering behavior.

The police report indicated that an Officer reviewed the video and photographs. The Police Officer from Anaheim PD indicated that he did not see any pushing in the video.

Based on the information gathered during the investigation and review of all documents obtained, the following allegations: Resident dispensed a medication not prescribed by physician, resident not administered medication as prescribed by physician, staff physically abused resident and staff handles resident in a rough manner are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted and a copy of this report was provided during the visit to Vanessa Batara, House Manager
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5