306005226-5-16-2025-22-AS-MSEY-DGTMDD-20250519093059

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005226
Report Date: 05/16/2025
Date Signed: 05/16/2025 03:08:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
11/16/2023 and conducted by Evaluator Cassandra Mikkelson

COMPLAINT CONTROL NUMBER: 22-AS-20231116152802

FACILITY NAME:	ARBOR PALMS OF ANAHEIM		FACILITY NUMBER:	306005226
ADMINISTRATOR:	YOUNG PARK		FACILITY TYPE:	740
ADDRESS:	3411 W BALL RD		TELEPHONE:	(714) 821-9660
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	0	CENSUS: 0	DATE:	05/16/2025
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Young Park		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not provide adequate supervision to resident in care resulting in resident sustaining falls and injury
Facility does not have enough staff to meet the needs of residents requesting assistance
Staff did not adequately appraise resident while in care

INVESTIGATION FINDINGS:

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On 05/16/2025, Licensing Program Analyst (LPA) Cassandra Mikkelson contacted the licensee via phone and left a message to deliver final findings regarding a complaint that was received on 11/16/2023. LPA Mikkelson left message with Young Park and explained the purpose of the call.

**Report continued on 9099-C Page**

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 709-6317
LICENSING EVALUATOR NAME: Cassandra Mikkelson	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

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-20231116152802

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ARBOR PALMS OF ANAHEIM	FACILITY NUMBER: 306005226
	VISIT DATE: 05/16/2025

NARRATIVE

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Staff did not provide adequate supervision to resident in care resulting in resident sustaining falls and injury.

Interviews conducted indicated that staff had safety protocols in place and did safety checks for residents. Interview conducted with Responsible Party (RP) indicated that when Resident R1 was moved into the facility, they were aware that R1 was a fall risk and put in proper protocols to help R1 have assistance. During R1’s stay at the facility, R1 was moved into the Memory Care unit due to change in condition. R1 was able to be more closely monitored. Based on interviews conducted and records reviewed, the allegation is unsubstantiated.

Facility does not have enough staff to meet the needs of residents requesting assistance.

Interviews with multiple staff indicated that there are enough staff to meet the needs of residents who needed assistance at the facility. Staff did not have any complaints regarding staffing. Based on interviews conducted, the allegation is unsubstantiated.

Staff did not adequately appraise resident while in care.

Interviews with staff indicated that R1 was appraised appropriately based on his care needs and level of care. Interview with previous Administrator indicated that the Licensed Vocational Nurses (LVN) on staff were responsible for assessing and monitoring residents for change in condition. Records reviewed indicated that staff were monitoring resident for change in condition and updated appraisals as needed and when R1 was moved to memory care. Based on interviews conducted and records reviewed, the allegation is unsubstantiated.

Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 709-6317
LICENSING EVALUATOR NAME: Cassandra Mikkelson	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

LIC9099 (FAS) - (06/04)

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