306005226-8-28-2024-22-AS-MSTC-D8NJ4H-20240831064308

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005226
Report Date: 08/28/2024
Date Signed: 08/28/2024 03:16:42 PM

Unsubstantiated

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
12/23/2020 and conducted by Evaluator Dwayne L Mason

COMPLAINT CONTROL NUMBER: 22-AS-20201223142101

FACILITY NAME:	ARBOR PALMS OF ANAHEIM		FACILITY NUMBER:	306005226
ADMINISTRATOR:	NANCY RODRIGEZ		FACILITY TYPE:	740
ADDRESS:	3411 W BALL RD		TELEPHONE:	(714) 821-9660
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	0	CENSUS: 0	DATE:	08/28/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Darlene Lindley, Administrator and Lea Wine, Assistant Administrator		TIME COMPLETED:	03:31 PM

ALLEGATION(S):

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Resident sustained injuries from a fall while in care
Staff did not notify an authorized representative of an incident involving a resident

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 receptionist. LPA met with Darlene Lindley, Administrator and Lea Wine, Assistant Administrator and explained the nature of the inspection.

The department received a complaint on 12/23/2020 stating a resident sustained injuries from a fall while in care and that staff did not notify an authorized representative of an incident involving a resident. During the investigation, the department interviewed facility staff and residents in care.

On 12/29/2020 and 10/21/2021, LPAs conducted visits to the facility to obtain documentation and conduct an interview with the facility’s current Administrator (AD1).

(continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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-20201223142101

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: ARBOR PALMS OF ANAHEIM	FACILITY NUMBER: 306005226
	VISIT DATE: 08/28/2024

NARRATIVE

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LPA Mason conducted a follow up visit. LPA obtained copies of the following files: resident roster, personnel roster, facility’s fall reduction program and incident reports.

LPA conducted phone interview with R1’s responsible party/family member (RP). RP confirmed R1 did not have other medical conditions and was informed the same day of the fall. RP stated R1 is unable to communicate verbally or show signs of comprehension when someone is speaking. LPA was unable to conduct interview with R1.

LPA contacted the hospice agency that R1 was reported to have hospice through. Based on interview with Hospice Agency Representative (HR), R1 was never enrolled in hospice through them. HR stated R1 was assessed in 2021 with their physician deciding they were not ready for hospice. HR stated they have no records for R1 during the year 2020.

LPA conducted interview with AD2. AD2 made no disclosures regarding the allegation. LPA requested R1’s resident file from the closed facility. AD2 searched the new facility’s file archives which contains some files from the closed facility. AD2 was unable to find any documentation regarding R1. LPA conducted interviews with staff who were employed by the facility in 2020. Caregivers (S1 and S2) stated rounds for all residents are conducted at least every 15 minutes and when a resident falls. All staff interviewed stated caregivers are to immediately notify a Medtech when a resident falls.

Based on record review, staff has indicated R1 had no prior history of fall which was also confirmed by RP. RP initially stated they were not informed of the incident, but later stated that they were informed the day of R1’s incident. Staff stated they did inform RP of the incident. LPA was unable to determine if resident sustained injuries from a fall while in care or if staff did not notify an authorized representative of an incident involving a resident. Based on interviews conducted and records reviewed there is insufficient evidence to support the allegation. Although the allegation(s) may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted, and this report was reviewed with Darlene Lindley, Administrator and Lea Wine, Assistant Administrator. A copy of this LIC-9099 was provided to the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC9099 (FAS) - (06/04)

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