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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004795
Report Date: 11/17/2020
Date Signed: 11/17/2020 11:42:11 AM



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
10/23/2020 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20201023103224
FACILITY NAME:WESTMINSTER VILLAFACILITY NUMBER:
306004795
ADMINISTRATOR:ANA KUNZFACILITY TYPE:
740
ADDRESS:13881 DAWSON STREETTELEPHONE:
(714) 534-7880
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:200CENSUS: 144DATE:
11/17/2020
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Ana KunzTIME COMPLETED:
10:25 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client did not receive AM and PM medication for 3 days
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Kimberly Lyman and Jennifer Tirre made an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry by Administrator Ana Kunz and explained the reason for the visit.
During the course of the investigation, LPAs toured the facility, interviewed staff, and witnesses as well as reviewed and obtained facility documents such as medication administration records (MAR) and physician orders. Regarding the allegation that client did not receive AM and PM medication for 3 days, the investigation revealed the following: Resident 1 (R1) stated that the resident missed pain medication, Baclofen for three days. Review of physician orders and MAR indicate Baclofen is ordered "As needed." Facility staff indicate the medication is given as requested from the resident and the medication has not been witheld. LPA is unable to observe any discrepencies in medication administration. Therefore the allegation is deemed UNFOUNDED, meaning the allegation was false, could not have happened and/or is without a reasonable basis.
A copy of this report was left at the facility.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
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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