306005261-10-21-2022-22-AS-AJLO-CKQT8T-20221031143053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005261
Report Date: 10/21/2022
Date Signed: 10/21/2022 03:32:19 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
05/02/2022 and conducted by Evaluator Kathrina Chin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220502105351

FACILITY NAME:	SWEETWATER SENIOR CARE		FACILITY NUMBER:	306005261
ADMINISTRATOR:	SALEEM MOOSANI		FACILITY TYPE:	740
ADDRESS:	5741 SWEETWATER PLACE		TELEPHONE:	(714) 496-7842
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 4	DATE:	10/21/2022
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Arely Luna Barrera & Paula Olivares & Fozia Moosani		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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1) Staff are not meeting hospice resident's care needs
2) Staff left resident in soiled clothing
3) Staff did not check on resident for extended period of time
4) Staff failed to ensure oxygen level was appropriate for hospice resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kathrina Chin conducted an unannounced visit for the purpose of delivering the findings on a complaint investigation. LPA met with Paula Olivares, Arely Luna Barrera and spoke to Saleem Moosani, Administrator on the telephone. LPA interviewed staff members, residents, witnesses and reviewed resident's records.

The investigation revealed the following:

An initial visit was made on May 10, 2022. R1 was admitted to the facility on April 20, 2022 in the early evening and was placed on hospice care on the same day. LPA interviewed two caregivers who were at the facility. Staff and Staff 2 stated that they R1 ate dinner on April 20, 2022 and that R1 ate well. The next day, Staff 1 and Staff 2 stated that R1 was fed an egg, oatmeal and Ensure for breakfast on April 21, 2022. Staff 1 and Staff 2 stated that both of them repositioned the R1 and changed R1's diaper the next morning. (Continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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-20220502105351

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: SWEETWATER SENIOR CARE	FACILITY NUMBER: 306005261
	VISIT DATE: 10/21/2022

NARRATIVE

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Seacrest Hospice sent a shower aide on the morning of April 21, 2022 and Staff 1 stated that she helped the aide to sponge bath the resident that morning. Sometime during the day of April 21, 2022, Staff 1 repositioned R1 and changed R1's diaper with the assistance with R1's friend of the family.

On April 20, 2022, the hospice nurse stated that she set R1's Oxygen Concentrator as ordered by the physician. It was alleged that facility staff changed the oxygen concentrator from 2.5 to 4 Liter. The Hospice nurse stated that the doctors orders for the oxygen is between 2 to 5 Liter. Staff 1 and Staff 2 stated that they never changed the level of the Oxygen Concentrator.

Resident 1 passed away on April 21, 2022 at approximately 1:30 PM.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted, appeal rights explained and provided. A copy of this report was provided during the visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

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