306004839-12-11-2023-22-AS-SSAS-CYG2SW-20231212163949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004839
Report Date: 12/11/2023
Date Signed: 12/11/2023 01:09:38 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
10/06/2020 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201006152005

FACILITY NAME:	FULLERTON VILLA		FACILITY NUMBER:	306004839
ADMINISTRATOR:	DARLENE LINDLEY		FACILITY TYPE:	740
ADDRESS:	2441 W. ORANGETHORPE AVE.		TELEPHONE:	(714) 992-5380
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	197	CENSUS: 174	DATE:	12/11/2023
		UNANNOUNCED	TIME BEGAN:	08:37 AM
MET WITH:	Facility Administrator - Darlene Lindley Assistant Administrator Jae Rim		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident sustained injuries from a fall while in care
Staff is threatening resident with eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility for the complaint received on 10/06/2020 and to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by facility administrator (AD) Darlene Lindley and Assistant Administrator Jae Rim.

During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed.

It was alleged that resident sustained injuries from a fall while in care. Per resident (R1) physician report, R1 is non-ambulatory and has a history of falling and wandering. R1 was also reported to have dementia with behavioral disturbances. On 9/29/2020 and 10/02/2020, the facility observed that R1 had redness around the eyes, to which the facility contacted medical care and R1 was sent to the hospital to obtain further evaluation and treatment, and reported the incidents to R1's family on the same day.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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-20201006152005

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: FULLERTON VILLA	FACILITY NUMBER: 306004839
	VISIT DATE: 12/11/2023

NARRATIVE

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R1 was placed on hospice on 10/01/2020 by R1’s responsible party and requested for 24 hour supervision to be conducted from the hospice agency.

It was alleged that the staff is threatening resident with eviction. Per interview with facility staff, it was revealed that facility staff will remind residents about the option of moving out of the facility if a resident is unhappy residing at the facility, however, per documentation review, there were no records of the facility issuing R1 with an eviction, or any documented warnings to R1 about an eviction. Following R1’s hospitalization on 10/02/2020, the facility followed up with R1’s responsible party to inquire about a return date, to which R1’s responsible party had stated that R1’s doctor suggested for R1 to live elsewhere to obtain a higher level of care, to which the family agreed, therefore, R1 did not return to the facility. Facility issued R1’s responsible party a refund and removed R1’s belongings out of the facility on 10/18/2020.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegations occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted with Assistant Administrator Rim.

A copy of this report was provided and explained.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

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