306004839-10-18-2023-22-AS-SSAS-CX5SHG-20231031135332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004839
Report Date: 10/18/2023
Date Signed: 10/18/2023 03:59:01 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
06/28/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230628100247

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: 181	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Darlene Lindley- Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained fracture due to staff neglect.
Staff are not meeting resident's laundry needs.
Staff did not safeguard resident's clothing.
Staff did not feed resident.
Staff did not properly dress resident.

INVESTIGATION FINDINGS:

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.Licensing Program Analyst (LPA) Jessica Cho arrived unannounced and met with Adminstrator Darlene Lindley for the purpose of delivering the findings into the above allegations.

On June 28, 2023, the Department received the complaint, and the investigation was initiated by LPA Kimberly Lyman on June 29, 2023. During the visit on June 29th, LPA Lyman obtained records and conducted the health and safety inspection, and there were no identified concerns observed at the time of the visit. On September 8, 2023, LPA Jessica Cho continued the complaint investigation, interviewed residents and staff, and obtained additional facility and resident records. Interviews were further conducted by LPA Cho via phone calls on September 27, 2023. The following are the findings investigated by the Department which involved a review of records and interviews pertaining to Resident #1 (R1):

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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 8

Control Number 22-AS-20230628100247

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: 10/18/2023

NARRATIVE

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It is alleged that the resident sustained a fracture due to staff neglect. R1 is diagnosed with Dementia as noted in the Physician’s Report dated April 19, 2023. On May 28, 2023, R1 sustained a fall per the Unusual Incident/Injury Report (UR). The investigation revealed that three out of the three staff confirmed during the interviews that R1 was able to walk without any physical assistance (e.g., walker, cane, or other person) however had unsteady gait prior to the fall. R1 received physical therapy to increase mobility and improve their gait as noted on the home health Progress Notes dated May 27, 2023. The Department reviewed the surveillance footage for May 28, 2023, capturing R1 falling face-down in an attempt to reach for the roommate’s left hand; and as a result, struck their right shoulder against the floor of the hallway. Based on interviews which were conducted, review of documents obtained, and observations, it is determined that there was insufficient evidence to corroborate R1 sustaining a fracture due to staff neglect as R1 was not evaluated as a fall risk. 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.

It is alleged that the staff are not meeting the resident’s laundry needs. In review of the staff’s personal laundry notes from January 2, 2023 to September 7, 2023, R1’s clothes were washed every Wednesdays. During those months, the staff was absent for three days: April 12, June 15, and June 16, 2023. Out of the three days, April 12th fell on a Wednesday which was the designated laundry day for R1. Staff stated that R1’s clothes were not washed on April 12th, however, were washed within the week. Per LPA’s review, staff could not recall nor has documented the day R1’s clothes were washed following their absence. Interviews conducted with a total of seven staff indicated that the resident’s clothing appeared clean. Five out of the seven staff confirmed that the dirty laundry was washed weekly while two out of the seven staff were unaware of the laundry schedule. Three out of the six residents expressed contentment with their weekly laundry service while two out of the six residents could not be interviewed as the residents exhibited cognitive impairments and disorientation. One remaining resident indicated that they did not opt to pay additional fees for the laundry service. Although the laundry notes for the week of April 12, 2023, did not document R1’s clothes were washed, the interviews reveal that R1’s clothing was observed to be clean in appearance. Therefore, the evidence obtained did not support the allegation. 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.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 22-AS-20230628100247

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: 10/18/2023

NARRATIVE

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It is alleged that the staff did not safeguard the resident’s clothing. Per review of R1’s Clothing and Possessions form dated February 2, 2021, there were no missing items that were reported. Two out of the two residents could not be interviewed as both are disoriented. Seven out of the seven staff stated that they did not have knowledge of R1 missing their clothing items, therefore the evidence collected did not support the allegation. 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.

It is alleged that the staff did not feed the resident. After R1’s fall on May 28, 2023, R1 sustained a surgical neck fracture to the right arm as noted on the X-Ray report dated May 31, 2023. As a result, R1 was unable to feed themself due to pain. Two out of the two residents could not be interviewed as both residents were cognitively impaired and disoriented. Five out of the five staff stated that R1 was fed every meal after the fall and was provided Ensure when food was refused. In addition, when R1 was hospitalized from the fall at the initial hospital, the patient progress notes dated May 28, 2023 documented R1’s height at 5’2” and R1’s weight to be at 120 lbs. The discharge summary notes from the final hospital documented R1’s weight to be 110 lbs with a total weight loss of 10lbs. The evidence obtained from the interviews and the medical records did not support the allegation. 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.

It is alleged that staff did not properly dress the resident. LPA was unable to interview R1 as R1 was not alert and oriented. Interviews conducted with five staff indicated that R1 was properly dressed and wore their own clothes during their stay at the facility. One staff who was present on June 9, 2023, when R1 was hospitalized, observed R1 being transported to the hospital with a blanket covering their exposed lower half of the body due to R1 refusing to wear their pants. The evidence obtained during the investigation did not support the allegation. 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 Administrator Darlene Lindley, and a copy of this report including the LIC9099-Cs, and the LIC811 were provided at the end of the visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 8

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
06/28/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230628100247

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: 181	DATE:	10/18/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Darlene Lindley- Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not notify resident's authorized representative of fracture in a timely manner.
Staff did not seek medical attention for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced and met with Administrator Darlene Lindley for the purpose of delivering the findings into the above allegations.

On June 28, 2023, the Department received the complaint, and the investigation was initiated by LPA Kimberly Lyman on June 29, 2023. During the visit on June 29th, LPA Lyman obtained records and conducted the health and safety inspection, and there were no identified concerns observed at the time of the visit. On September 8, 2023, LPA Jessica Cho continued the complaint investigation which was comprised of interviews with residents and staff and obtaining additional facility and resident records. Interviews were further conducted by LPA Cho via phone calls on September 27, 2023. The following are the findings investigated by the Department which involved a review of records and interviews pertaining to Resident #1 (R1):

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 22-AS-20230628100247

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: 10/18/2023

NARRATIVE

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It is alleged that the staff did not notify the resident’s authorized representative of the fracture in a timely manner. In review of the records obtained, the following is a chronological timeline of events beginning from the date of the fall: On May 28, 2023, R1 sustained a fall as noted on the Unusual Incident/Injury Report (UR). R1 was admitted to the hospital and returned to the community the same day. The medical records dated May 28, 2023, reveal that R1 did not sustain a fracture/dislocation however presented calcific rotator cuff tendinitis, moderate acromioclavicular joint space arthrosis, and mild glenohumeral degenerative change with acute Urinary Tract Infection (UTI). R1 was prescribed medications to treat the UTI and alleviate shoulder pain. On May 29, 2023, staff observed R1 in pain and requested an X-ray of R1’s primary care physician (PCP) as documented on the M.D. Order. In response, the PCP authorized an X-Ray of the right arm, shoulder, and hip which the order was received by the facility on May 31, 2023, at 10:12am. On May 31, 2023, at 3:25pm, the X-Ray revealed R1 sustaining a surgical neck fracture to the right arm. The X-Ray finding was received by the facility the same day at 9:43pm. The administrator admitted locating the X-ray results on June 9, 2023, which was nine days after receiving the results. Therefore, R1’s authorized representatives were notified nine days after the x-ray results were received. It is determined that the above allegation occurred as reported, therefore, the allegation is substantiated, meaning that the preponderance of evidence standard has been met.

It is alleged that the staff did not seek medical attention for the resident. The surveillance footage of the fall on May 28, 2023, obtained by the Department reveals that an unknown staff responded to the incident within approximately ten seconds and a supervisor arrived within approximately one minute. 911 was called and the Fullerton Fire Department arrived at the scene within eighteen minutes. Although the response to the incident was timely, the handling of the X-Ray result of a fracture was not timely. The result of the X-ray indicating a right humeral head/surgical neck fracture was faxed to the facility on May 31, 2023, at 10:12am. Per interview with Staff #1 (S1), S1 stated that she is responsible to process medical records however was reassigned with a different duty and did not see the X-Ray results come through for R1. S1 indicated that she saw the X-Ray results while reviewing R1’s file and subsequently transferred R1 to the hospital for evaluation on June 9, 2023.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 22-AS-20230628100247

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: 10/18/2023

NARRATIVE

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Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation Staff did not seek medical attention for resident is deemed SUBSTANTIATED per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. Two deficiencies are being cited on the following LIC9099-D.

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49.

An exit interview was conducted with Administrator Darlene Lindley, and a copy of this report including the LIC9099-Cs, LIC9099-D, LIC811, and the appeal rights were provided at the end of the visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 22-AS-20230628100247

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/25/2023 Section Cited CCR 87705(b)(1)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (b) In addition to the requirements as specified in…the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator… when a resident’s behavior or condition changes. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The administrator stated they will train their staff and provide proof of training addressing cited regulation to LPA via email by POC due date.
	8 9 10 11 12 13 14	Based on LPA’s interviews and record review, two out of two staff made an admission that the authorized representative was notified 9 days after receiving the x-ray result which poses a potential Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 22-AS-20230628100247

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/19/2023 Section Cited CCR 87446	1 2 3 4 5 6 7	87446 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The administrator stated they will develop procedures to track medical orders and medical exam or test results and will train their staff. The proof of training addressing cited regulation will be provided to LPA via email by POC due date.
	8 9 10 11 12 13 14	Based on LPA's interviews and record review, two out of the two staff confirmed not seeking medical attention in a timely manner due to discovering the x-ray results 9 days later which poses an immediate Health, Safety, and Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 8