306004839-7-8-2021-22-AS-MSTC-C4S2JG-20210709172617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004839
Report Date: 07/07/2021
Date Signed: 07/08/2021 12:19:45 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
04/07/2020 and conducted by Evaluator Lydia Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200407135246

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: 124	DATE:	07/07/2021
		UNANNOUNCED	TIME BEGAN:	06:00 PM
MET WITH:	Darlene Lindley		TIME COMPLETED:	07:00 PM

ALLEGATION(S):

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* Staff not meeting resident needs resulting in resident being hospitalized.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to deliver findings on the above allegation. LPA Martinez met with Administrator Darlene Lindley and explained the reason for the visit.

During the course of the investigation, LPA interviewed staff as well as reviewed and obtained pertinent documentation such as Physician’s Report dated 02/19/2020, Resident Appraisal dated 12/13/2019, Appraisal Needs and Service Plan dated 03/09/2020, Resident Meal Intake Sheet dated 03/09/2020 thru 03/29/2020, and St. Jude Medical Center medical records dated 03/29/2020.

Interview with Administrator, staff, family/POA and review of documents revealed the following: Resident 1 (R1) was admitted to the facility on 03/01/2020 and needed assistance with all Activities of Daily Living (ADL), including one on one feeding.

(see LIC9099C...cont.)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

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-20200407135246

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: 07/07/2021

NARRATIVE

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Administrator stated R1 was on pureed food. Review of Resident’s Meal Intake sheet, R1 had 8 oz of juice, 8 oz of milk and 8 oz. of water at each meal. Power of Attorney (POA) was asked to bring supplement Ensure because R1 was eating 100% of the meal but was still hungry. POA also brought R1 a large tumbler to set on side of table for R1 to sip between meals. This was acknowledged during an interview between R1’s POA and LPA Martinez.

R1’s POA stated the facility staff were not meeting R1’s needs but could not support her statement with evidence or explain in what way the staff was not meeting R1’s needs. POA stated R1 lies in the bed and staff provide what R1 needs. POA stated that the facility Nurse told her that R1 was disoriented, was weak and was having shortness of breath therefore was being sent to the hospital. POA stated ER doctor told her that R1 was malnourished, dehydrated and had a UTI and therefore POA concluded that the R1 needs were not met.

Review of St. Jude Medical records dated 03/29/2020 revealed R1 arrived at the hospital on 03/29/2021 with generalized weakness and shortness of breath. R1’s weight was 112.8 lbs. when admitted. Review of R1’s Physician’s Report, R1’s weight was 115 lbs on 02/19/2020. R1’s admitting diagnosis were the following: 1. Acute Kidney injury on chronic kidney disease, Stage IV, 2. Hyperkalemia, 3. UTI, 4. Possible pneumonia, 5. Hypertension, 6. History of Congestive Heart Failure, 7. Dysphagia, 8. Hypothyroidism, 9. Hyperlipemia, 10. Dementia, 11. Major Depression, 12. Anxiety, 13. Glaucoma, 14. Gastroesophageal reflux disease.

Based on interviews conducted and documents reviewed there is no corroboration that R1 was admitted to the hospital due to being malnourished and/or dehydrated. Therefore, the allegation is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Administrator Lindley and a copy of this report was provided.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

LIC9099 (FAS) - (06/04)

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