306004795-4-14-2022-22-AS-AORZ-CDPMHQ-20220421093751

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004795
Report Date: 04/14/2022
Date Signed: 04/14/2022 10:50:26 AM

Unfounded

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
01/03/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220103080936

FACILITY NAME:	WESTMINSTER VILLA		FACILITY NUMBER:	306004795
ADMINISTRATOR:	PATTY OSUNA		FACILITY TYPE:	740
ADDRESS:	13881 DAWSON STREET		TELEPHONE:	(714) 534-7880
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92843
CAPACITY:	200	CENSUS: 121	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Patty Osuna and and Alex Jones		TIME COMPLETED:	11:08 AM

ALLEGATION(S):

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Staff gave resident discontinued medication
Staff refused to order resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (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 investigation, LPA toured the facility, reviewed and obtained pertinent documentation such as medication administration records and hospital paperwork as well as interviewed staff and witness. Regarding the allegations that staff gave resident discontinued medication and staff refused to order resident's medication, the investigation revealed the following: R1 was hospitalized on 10/20/2021 for psychiatric evaluation and returned to the facility on 11/01/2021 with new medication orders. Per interviews with witness and facility staff, facility contacted the pharmacy with revised orders by fax on 11/01/2021 when resident returned. Facility provided proof of fax to LPA. Resident was sent back out to the hospital on 11/03/2021 and has not returned to the facility to date. Witness indicates an antibiotic medication for a dental infection was not filled by the facility however in interviews, CONT ON LIC 9099C DATED 04/14/2022

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: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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-20220103080936

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: 04/14/2022

NARRATIVE

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witness cannot determine the timeline. Facility provided proof of medication order for a dental infection dated 08/24/2021 and medication administration record verifies resident was given the medication. Therefore the allegations are deemed UNFOUNDED, meaning the allegations are was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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