306004795-9-26-2023-22-AS-AORZ-CW5QAR-20230929120022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004795
Report Date: 09/26/2023
Date Signed: 09/26/2023 02:42:34 PM

Unsubstantiated

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
02/25/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220225164530

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: 126	DATE:	09/26/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Patty Osuna and Alexis Jones		TIME COMPLETED:	03:02 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care

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 allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as physician report and resident appraisal. Regarding the allegation that resident sustained an unexplained injury while in care, the investigation revealed the following: On 02/24/2022, Resident 1 (R1) was found on the floor by staff. Resident was evaluated to have no pain but was sent out to UCI for observation. Resident did not return to the facility and had been known to be residing at Alta Gardens Care Center. Witness indicated that resident was admitted into UCI and diagnosed with a trace subdural hemorrhage and a left humerus fracture. Resident had a diagnosis of Parkinson's Disease. Resident was transferred to Alta Gardens Center where the resident currently resides. On 09/19/2023, LPA conducted a collateral visit to Alta Gardens Care Center and met with the Executive Director (ED). CONTINUED ON LIC 9099C DATED 09/26/2023

Unsubstantiated

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: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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-20220225164530

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: 09/26/2023

NARRATIVE

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ED indicated resident had been residing at the skilled nursing since February 2022 and was stable. ED confirmed Parkinson's diagnosis as well as Dementia. LPA met with the resident who was unable to speak with LPA due to Dementia diagnosis. Resident appeared clean and well taken care of and was participating in an activity. Per physician report dated 10/22/2019, R1 is diagnosed with hyperlipidemia and gastroesophageal disease, is independent, and can leave the facility unassisted. Facility indicated that there was no diagnosis of Parkinson's Disease while resident was at Westminster Villa and indicated resident was being seen by a physician regularly throughout the pandemic. Resident is noted to have one prior fall on 02/23/2022 with no injury or hospitalization. When resident fell on 02/24/2022, R1 was sent out for observation despite resident declining medical assistance. Two out of two staff interviewed at facility indicated no observation of resident decline at time of fall. While resident did have a fall resulting in an injury, facility sent the resident out for observation. Facility provided documentation of resident observation every two hours. Due to conflicting information, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and copy of the 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: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC9099 (FAS) - (06/04)

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