306004795-5-10-2021-22-AS-AORZ-C2ZRPE-20210514131148

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004795
Report Date: 05/10/2021
Date Signed: 05/10/2021 02:11:14 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
12/10/2020 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20201210142832

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:	05/10/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Ana Kunz		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulting in resident suffering a fall while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Lyman contacted the facility via telephone to deliver findings on a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and elements of allegations with Administrator Ana Kunz.

During the course of the investigation, LPA toured the facility, interviewed staff and witness, as well as reviewed and obtained pertinent documentation such as physician report and PRN authorization letter. Regarding the allegation that lack of supervision resulting in resident suffering a fall while in care, the investigation revealed the following: On 12/09/2020, Resident 1 (R1) had an unwitnessed fall in the parking lot of facility. R1 was discovered by staff and 911 was called. R1 had a bump on the head and labored breathing. Parmedics responded and transported R1 to UCI Medical Center. Per R1's family member, R1 had minor injuries. R1 did not return to facility and is currently housed at a different facility, name unknown per family member. R1's physician report dated 02/18/2020 indicated R1 is allowed to leave the facility unattended and facility staff state it was common practice CONT ON LIC 9099C DATED 05/10/21

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: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 22-AS-20201210142832

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: 05/10/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

for R1 to leave to go on walks or to the store. It is presumed that R1 was returning from a visit to the store when she fell as she had grocery items with her. Therefore the allegation is deemed UNFOUNDED, meaning the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Administrator Ana Kunz via telephone and a copy of this report was provided to Administrator via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2