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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005211
Report Date: 09/27/2022
Date Signed: 09/27/2022 03:20:09 PM

Substantiated


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
07/13/2022 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220713140341
FACILITY NAME:ARDENT CAREFACILITY NUMBER:
306005211
ADMINISTRATOR:MELINDA FLORESFACILITY TYPE:
740
ADDRESS:1665 SOUTH BROOKHURST STREETTELEPHONE:
(714) 991-0991
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:27CENSUS: 25DATE:
09/27/2022
UNANNOUNCEDTIME BEGAN:
11:43 AM
MET WITH:Melinda FloresTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Facility staff failed to provide First Aid to resident injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to continue the investigation into the above allegations and to deliver the findings of the investigation. LPA Velazquez was allowed entry into the facility and met with Melinda Flores and explained the purpose of the visit.

On today's visit LPA Velazquez conducted interviews with staff. During the course of the investigation LPA reviewed facility, staff, and resident records. LPA also conducted interviews with the complainant, residents and staff. The individuals interviewed were able to corroborate the above allegation. Records reviewed included Resident Incident Reports, Facility Sign -In Sheets, Physician's Reports, Facility Communication Logs, Resident (R) #3's Medication Administration Record, California Assisted Living Waiver (ALW) Program Individual Service Plan, Service Notes, Beachside Nursing Center Records, La Palma Intercommunity Hospital After Visit Summary dated 03/10/2021, pictures documenting R3's bruising, and Ardent Care Daily Body Check
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
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 5
Control Number 22-AS-20220713140341
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: ARDENT CARE
FACILITY NUMBER: 306005211
VISIT DATE: 09/27/2022
NARRATIVE
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Report documenting R3's bruising. Regarding the allegation: Facility staff failed to provide First Aid to resident injury, the staff interviewed confirmed they did not provide any First Aid treatment to R3 when R3 was observed with bruising on their face. The facility records reviewed did not document that any First Aid treatment was provided to R3.

Based on the observations made, interviews which were conducted, and the records reviewed, the preponderance of evidence standard has been met, therefore the allegation of Facility staff failed to provide First Aid to resident injury is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 is being cited on the attached LIC 9099 D.


An exit interview was conducted with Melinda Flores and a copy of this report along with the appeal rights, LIC 9098 and LIC 811 were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/13/2022 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220713140341

FACILITY NAME:ARDENT CAREFACILITY NUMBER:
306005211
ADMINISTRATOR:MELINDA FLORESFACILITY TYPE:
740
ADDRESS:1665 SOUTH BROOKHURST STREETTELEPHONE:
(714) 991-0991
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:27CENSUS: 25DATE:
09/27/2022
UNANNOUNCEDTIME BEGAN:
11:43 AM
MET WITH:Melinda FloresTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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2
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5
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9
Facility failed to notify responsible party of injuries
INVESTIGATION FINDINGS:
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3
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5
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13
Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to continue the investigation into the above allegations and to deliver the findings of the investigation. LPA Velazquez was allowed entry into the facility and met with Melinda Flores and explained the purpose of the visit.

On today's visit LPA Velazquez conducted interviews with staff. During the course of the investigation LPA reviewed facility, staff, and resident records. LPA also conducted interviews with the complainant, residents and staff. Records reviewed included resident Incident Reports, Facility Sign -In Sheets, Physician's Reports, Facility Communication Logs, Resident (R) #3's Medication Administration Records, California Assisted Living Waiver (ALW) Program Individual Service Plan, Service Notes, Beachside Nursing Center Records, La Palma Intercommunity Hospital After Visit Summary dated 03/10/2021, text communication between facility staff and complainant, photos documenting R3's bruising and Ardent Care Daily Body Check Report. Regarding the
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20220713140341
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: ARDENT CARE
FACILITY NUMBER: 306005211
VISIT DATE: 09/27/2022
NARRATIVE
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allegation: Facility failed to notify responsible party of injuries, the individuals interviewed providing conflicting statements and could not corroborate the allegation. The facility documented the submission of an Incident Report to Licensing on July 4, 2022 at 10:20 AM where the report documented R3's family was notified of R3's injury. The facility sign-in sheets documented R3's responsible party checking in at 10:38 AM on July 4th.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the following allegation: Facility failed to notify responsible party of injuries is deemed UNSUBSTANTIATED.


An exit interview was conducted with Melinda Flores and a copy of this report along with the LIC 811 were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20220713140341
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: ARDENT CARE
FACILITY NUMBER: 306005211
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2022
Section Cited
CCR
87465(j)
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In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives needed first aid and needed emergency medical services...staff. This requirement was not met as evidenced by: based on observation, interview and record review the licensee did not provide first aid to R3 when R3's injury was noted. This poses an immediate risk to the health and safety of residents in care.
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Licensee to ensure each resident receives needed first aid pursuant to regulation. Licensee to conduct staff training and submit written proof to LPA by POC due date. Licensee to submit a written statement to LPA indicating they have read this section of regulation and how exactly they intend to adhere to it by 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.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5