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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004795
Report Date: 07/02/2021
Date Signed: 07/02/2021 12:42:54 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
06/29/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20210629141449
FACILITY NAME:WESTMINSTER VILLAFACILITY NUMBER:
306004795
ADMINISTRATOR:PATTY OSUNAFACILITY TYPE:
740
ADDRESS:13881 DAWSON STREETTELEPHONE:
(714) 534-7880
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:200CENSUS: 130DATE:
07/02/2021
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Ana KunzTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility staff is not allowing resident back in the facility after being discharged from the hospital
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to initiate the investigation on the above allegations. LPA was greeted and granted entry by Chief Executive Officer (CEO) Ana Kunz and explained the reason for the visit. Administrator Patty Osuna was present as well.
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 hospitalization records. Regarding the allegation that facility staff is not allowing resident back in the facility after being discharged from the hospital, the investigation revealed the following: Resident 1 (R1) was hospitalized on 06/23/2021 for vomiting/ gastroenteritis. Facility informed by hospital social worker that R1 is positive for Methicillin Resistant Staphylococcus Aureus (MRSA). Facility advised hospital that MRSA positive residents are not allowed in Community Care Licensing Facilities and asked about a referral to a skilled nursing facility for treatment. Physician indicated on discharge instructions that R1's nares were positive and no treatment or isolation was necessary. R1 was discharged from Anaheim Global back to the facility on 06/28/2021. R1 has a history of positive MRSA diagnosis. LPA interviewed R1 in. CONTINUED ON LIC 9099C DATED 07/02/2021.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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-20210629141449
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: 07/02/2021
NARRATIVE
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the facility who stated the resident had been back at the facility since the prior Monday. 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 CEO Ana Kunz via telephone and a copy of this report was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
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