306004839-11-14-2022-22-AS-AORZ-CLALMM-20221118075258

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004839
Report Date: 10/28/2022
Date Signed: 11/14/2022 12:45:37 PM

Unfounded

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
10/25/2022 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221025171349

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: 167	DATE:	10/28/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Darlene Lindley, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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1/ Facility charged residents in excess (this allegation was amended to align with Title 22 regulations)

2/ Staff accepted residents for hospice care who do not meet eligibility for a hospice care plan

INVESTIGATION FINDINGS:

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(This report was amended)
Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required complaint investigation into the allegations listed above. LPA arrived at facility, was greeted and granted entry by Darlene Lindley, Administrator after explaining the purpose of the visit. LPA additionally detailed the allegations being investigated at this time.

LPA requested and obtained the facility resident census, staff roster as well of lists of residents admitted under the Assisted Living Waiver (ALW) as well as the residents receiving hospice care at the time of the visit. LPA requested administrative, medical and applicable hospice records for a sample of seven (7) residents. At the time of the visit, 84 residents are noted to be part of the ALW Program. 13 residents are currently on hospice, which is within the 25 authorized capacity of the facility's hospice waiver.

CONTINUED ON FORM 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

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-20221025171349

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: 10/28/2022

NARRATIVE

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CONTINUED FROM FORM LIC9099

The randomly selected records for residents admitted all displayed admission agreements and/or updated yearly month-to-month leases with rates found to be consistent with the approved rates. Based on the records reviewed and interview conducted, the allegation that the "Facility charged residents in excess" is deemed to be unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

With no exception, hospice records reviewed by LPA are found to be consistent with the eligibility criteria for admission on hospice. All records provided include a primary diagnosis related to the placement as well as appropriate medical assessment and physician orders. The hospice records for resident R1 are however missing the required plan of care. A Technical Advisory to that effect is being issued to the licensee. LPA additionally interviewed the facility's administrator regarding the facility's hospice policy and observed the condition of multiple residents on hospice care during the visit. Based on the records reviewed, observations made and interview conducted, the allegation that "Staff accepted residents for hospice care who do not meet eligibility for a hospice care plan" is deemed to be unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

A exit interview was conducted with the facility representative and a copy of the report was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022

LIC9099 (FAS) - (06/04)

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