306004795-1-28-2022-22-AS-MVAO-CBHSY2-20220210131648

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004795
Report Date: 01/28/2022
Date Signed: 01/28/2022 01:45:23 PM

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
04/26/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20210426130649

FACILITY NAME:	WESTMINSTER VILLA		FACILITY NUMBER:	306004795
ADMINISTRATOR:	ANA KUNZ		FACILITY TYPE:	740
ADDRESS:	13881 DAWSON STREET		TELEPHONE:	(714) 534-7880
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92843
CAPACITY:	200	CENSUS: 129	DATE:	01/28/2022
		UNANNOUNCED	TIME BEGAN:	01:41 PM
MET WITH:	Patty Osuna and Alexis Jones		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Resident is not being allowed to return to the facility.
Facility mismanaged resident's medications.
Facility did not arrange for resident's use of a wheelchair.
Facility does not adequately communicate with residents.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Kimberly Lyman made an unannounced visit to the facility to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by Administrator Patty Osuna and explained the reason for the visit. Care Coordinator Alexis Jones was present as well.
During the course of the investigation, LPA toured Resident 1's (R1) room, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as medication orders and physician report. Regarding the allegations that facility does not adequately communicate with residents, facility mismanaged resident's medications, facility did not arrange for resident's use of a wheelchair, and resident is not being allowed to return to the facility, the investigation revealed the following: Five out of five witnesses interviewed state R1's roommate is currently resides at a skilled nursing facility and is not able to return at this time. Roommate has been at a skilled facility since approximately October 2020. Facility states the roommate is able to return once medically cleared. Facility does not share information with residents regarding why a resident may be leaving the facility. R1's physician report states resident may not manage own medications however physician has allowed. CONT ON LIC 9099C DATED 01/28/2022

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

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-20210426130649

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: WESTMINSTER VILLA	FACILITY NUMBER: 306004795
	VISIT DATE: 01/28/2022

NARRATIVE

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Benadryl creme and Aspercreme at the bedside. LPA observed both cremes during a tour of R1's room. Resident's medication orders matched medication administration record during review. LPA observed the resident's wheelchair as well. Resident was using the wheelchair as storage during time of visit. Therefore the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis.
An exit interview was conducted with Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC9099 (FAS) - (06/04)

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