306004795-9-19-2023-22-AS-AORZ-CWNRP3-20231016131116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004795
Report Date: 09/19/2023
Date Signed: 09/19/2023 11:12:51 AM

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
04/22/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220422163644

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: 119	DATE:	09/19/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Patty Osuna		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Resident fell and sustained an injury due to broken shower chair
Resident's bathroom in disrepair
Staff discarded resident medications (not expired)
Staff did not safeguard resident's personal items
Staff retaliate against resident for keeping roommates family informed
Staff do not ensure that resident's toileting needs are met
Staff do not respond to resident's call for assistance in a timely manner

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 and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and resident as well as reviewed and obtained pertinent documentation such as physician report and medication administration record. Regarding the allegations that resident fell and sustained an injury due to broken shower chair, resident's bathroom in disrepair, staff discarded resident medications (not expired), staff did not safeguard resident's personal items, staff retaliate against resident for keeping roommates family informed, staff do not ensure that resident's toileting needs are met, and staff do not respond to resident's call for assistance in a timely manner, the investigation revealed the following: Facility provided hospital records for Resident 1 (R1) dated 03/15/2020 for a CT scan of the head. Scan was negative with normal results. Facility indicates only visit/documentation for an evaluation of a fall. Resident is unable to provide dates as to when the fall/ hospital visit occurred. LPA observed the resident's CONT ON LIC 9099C DATED 09/19/2023

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: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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-20220422163644

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: 09/19/2023

NARRATIVE

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bathroom during the visit. LPA observed a clean bathroom with an intact shower chair and intact toilet seat. Toilet flushed properly with no back up. R1 states reporting the clogged toilet on 04/20/2022. Facility provided documentation of facility work order to unclog the toilet on 04/20/2022. Documentation indicates work was performed same day. The allegation that "staff do not respond to resident's call for assistance in a timely manner" is referring to time frame of correction of clogged toilet and not care of resident and work was documented to be timely. LPA observed restrooms in common areas available for the resident to use in the interim. R1 was self-managing medications until physician order dated 06/15/2021 which indicated facility was to begin medication administration. Physician order indicated resident was unable to store medications in room. Per facility, a sweep of the room was done and expired medications and pain patches were discarded. R1 is unable to provide which unexpired medications were discarded. Facility indicated giving R1 a warning and possible eviction notice regarding cleaning the room as hoarding conditions were observed to be a safety issue. Facility removed expired food from the room as well as trash. R1 is unable to provide which personal items were not safeguarded. Facility denies any type of retaliation towards R1 and indicates R1's roommate was moved to a different room as resident was declining and needed closer observation on the first floor of facility. Due to conflicting information, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and copy of the report was provided.

*This is an amended report to address a change of verbiage in report narrative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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