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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005195
Report Date: 11/19/2024
Date Signed: 11/19/2024 05:01:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
10/31/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20241031112257
FACILITY NAME:EMBASSY RESIDENTIAL CARE IIFACILITY NUMBER:
306005195
ADMINISTRATOR:KON, CORAFACILITY TYPE:
735
ADDRESS:1621 E SANTA ANA STREETTELEPHONE:
(714) 732-7217
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:6CENSUS: 4DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cora Kon - AdministratorTIME COMPLETED:
05:13 PM
ALLEGATION(S):
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Staff failed to contact 911 during medical emergency
Staff failed to report medical emergency via SIR to RCOC/ CCL
INVESTIGATION FINDINGS:
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This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by facility staff. LPA met with Cora Kon, Administrator and explained the nature of the inspection.

The department received a complaint on 10/31/2024 stating Facility failed to contact 911 during an medical emergency and that staff failed to report medical emergency via SIR to RCOC/CCL. During the investigation, the department interviewed the Administrator (AD), staff and clients in care.

On 11/6/2024 LPA conducted a visit to the facility. LPA obtained photos of the staff roster dated 1/1/2022, client roster, Physician's Report, Behavior progress reports, signed abuse disclosures, and progress notes.

(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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 3
Control Number 22-AS-20241031112257
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: EMBASSY RESIDENTIAL CARE II
FACILITY NUMBER: 306005195
VISIT DATE: 11/19/2024
NARRATIVE
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LPA reviewed the 10/18/2024 Progress Notes (PN). Per PN, while S1 and S2 were preparing dinner, they overheard C2 ask C1 if they were ok. S1 checked C1's room and "noted [a] few drops of red fluid on the bedroom floor." S1 found C1 in the bathroom washing their face. S1 observed "a small amount of blood coming out of [C1's] nose." S1 and AD asked C1 if they wanted to go to the hospital and C1 refused.

LPA conducted interviews with AD, 2 staff and 3 clients. AD, S1 and S2 corroborated the 10/18/2024 progress notes. S1 and S2 stated they don't know how much blood was on C1's face before C1 washed it. S1 and S2 stated the "red fluid" in C1's room was blood. AD,S1 and S2 stated they don't know what caused the bleeding. C2 and C3 stated they don't know what caused the bleeding.

On 11/19/2024, LPA reviewed C1's Individualized Program Plan (IPP). The IPP is dated 1/29/2024. In the "Additional Information" section, the IPP mentions C1's history of being found on the floor with no recollection of how they got there. The IPP states this may occur due to C1 not taking blood pressure medication. The IPP reads "[Service Coordinator] discussed the need to address whatever is going on with these incidents and it was noted that it is unclear if [C1] had a seizure or if [they] passed out due to [their] blood pressure and as such [they] would be taken with... PCP [Primary Care Physician]". The IPP makes mention that C1 voiced their willingness to follow the instructions of their Primary Care Physician.

On 11/6/20204, while at the facility, LPA reviewed the Department's Special Incident Report Log. LPA noted that the facility had not reported the incident. LPA noted 11/6/2024 marked 25 days since the incident.

Based on interviews conducted and records reviewed, LPA determined the facility did not ensure that C1 receive needed medical services. C1's most recent IPP indicates a concern regarding past incidents in which the cause is unclear. Per the IPP, there is a need to communicate with C1's PCP incidents like this occur. Per the IPP, C1 is willing to follow instructions from their PCP, however, according to three out of three interviews with staff, the facility did not know the cause of the incident and they did not contact C1's PCP.
Based on records reviewed, the facility did not report the incident to licensing in a timely manner.

The preponderance of evidence standard has been met. The allegations are determined to be SUBSTANTIATED, meaning the complaint allegations are valid and that two violations occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20241031112257
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EMBASSY RESIDENTIAL CARE II
FACILITY NUMBER: 306005195
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/10/2024
Section Cited
CCR
87211(a)(1)(D)
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87211(A)(1)(D) REPORTING
REQUIREMENTS (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of...(D) Any incident which threatens the welfare, safety or health of any resident.
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Adminsitrator stated they will conduct an
in-service training with all staff regarding
reporting requirements. AD stated they will
document the topics covered, staff in
attendance and date/time of the training. AD
stated they will email LPA documentation
related to training by the POC due date.
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Based on interviews conducted and records
reviewed, the licensee did not comply with the
above regulation due to the facility not reporting aggressive acts to staff by a resident.
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Type B
12/10/2024
Section Cited
CCR
80075(a)
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80075(a) HEALTH RELATED SERVICES (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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AD stated they will conduct an in-service training regarding Emergency Medical Services. AD stated they will document the topics covered, staff in attendance and date/time of the training. AD stated they will email LPA documentation related to training by the POC due date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3