306005349-7-7-2022-22-AS-MVAO-CHUSVK-20220901141253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005349
Report Date: 07/07/2022
Date Signed: 07/07/2022 11:25:30 AM

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
03/12/2021 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210312123703

FACILITY NAME:	LAS PALMAS		FACILITY NUMBER:	306005349
ADMINISTRATOR:	MONICA CASTILLO		FACILITY TYPE:	740
ADDRESS:	24962 CALLE ARAGON		TELEPHONE:	(949) 586-3393
CITY:	LAGUNA WOODS	STATE: CA	ZIP CODE:	92637
CAPACITY:	220	CENSUS: 140	DATE:	07/07/2022
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Monica Castillo		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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-Resident sustained pressure sore while in care

-Resident was subjected to medical procedure without consent from their responsible party.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrive at facility was greeted by receptionist and granted entry. LPA spoke with Monica Castillo, Administrator and explained the purpose of the visit.

Findings are based upon this investigation which included interviews conducted, and review of records.
It is alleged resident sustained pressure sore while in care. Records review revealed that on March 08, 2021 physician’s communication log indicates that R1 had some redness in upper coccyx area. On the same date a hospice referral was faxed to Carechoice and R1 was admitted to hospice. On March 09, 2021 visit from hospice notes states: assessed coccyx with hospice RN case manager, area is reddened, skin is intact, and new order for topical cream carried out. It is alleged resident was subjected to medical procedure without consent from their responsible party. Records review revealed that LIC601 Identification and emergency information form

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

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-20210312123703

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: LAS PALMAS	FACILITY NUMBER: 306005349
	VISIT DATE: 07/07/2022

NARRATIVE

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dated 12/29/2015 indicates R1 is responsible party for self and signed by R1. Advanced healthcare directive for R1 states if R1 is unable to make medical decisions for yourself then and only then R1 appointed an alternative agent. Admissions agreement dated 12/31/2015 reflect R1 to initial and sign document. Furthermore, facility received an updated physician’s report for R1 due to change in condition that required R1 to move to memory care unit. It was not until then that the responsible party changed to alternative agent. The admissions agreement for memory care unit effective date was 03/03/2021 which was signed by responsible party. First medical procedure performed on 02/11/2021 which would require consent by R1. Second procedure was done 03/04/2021 and records reflect that on 03/01/2021 at 1200 hours R1’s responsible party was informed, and consent was given. Base on the conflicting information received from interviews, information received by records and the lack of corroborating witnesses to the incidents, LPA is unable to determine if the alleged violations occurred as reported.

Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, these allegations are deemed Unsubstantiated.

An exit interview was conducted with Administrator and a copy of this LIC9099 report was left at facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC9099 (FAS) - (06/04)

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