306005350-9-16-2020-22-AS-MSTC-BTQ723-20200922211603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005350
Report Date: 09/16/2020
Date Signed: 09/16/2020 04:16:26 PM

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
02/04/2020 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200204080733

FACILITY NAME:	REGENCY, THE		FACILITY NUMBER:	306005350
ADMINISTRATOR:	DEBORAH BROWN		FACILITY TYPE:	740
ADDRESS:	24441 CALLE SONORA		TELEPHONE:	(949) 830-8057
CITY:	LAGUNA WOODS	STATE: CA	ZIP CODE:	92637
CAPACITY:	220	CENSUS: 101	DATE:	09/16/2020
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Justine Ortiz		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

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• Facility staff caused injury to resident in care
• Facility Staff improperly transferred resident resulting in multiple falls

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez contacted the facility via tele-visit due to COVID-19 precautionary measures to deliver findings for the investigation into the above identified complaint allegations. LPA spoke with Justine Ortiz, Administrator and explained the purpose of the telephone call.

The investigation was conducted by the Bureau of Investigations. Findings are based upon this investigation which included file review, interviews and medical records.

It is alleged that facility staff caused injury to resident in care and facility staff improperly transferred resident resulting in multiple falls. Resident #1 (R1) has resided at the Regency since 06/27/2015. R1 has right sided weakness from prior stokes, needing assistance with transferring to and from bed and/or wheelchair. Report received at CCL indicate staff #2 (S2) requested assistance when R1 fell during a transfer in room

CONTINUED ON LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020

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-20200204080733

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: REGENCY, THE	FACILITY NUMBER: 306005350
	VISIT DATE: 09/16/2020

NARRATIVE

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(transferring from wheelchair to chair). Staff arrived to provide aid, assessed incident and activated 911. S1 explained proper transferring technique is a two-step process: assist resident to stand up then pivot and sit the resident down on the bed or chair (gait belt not necessary for all residents). S1 reported S2 improperly transferred R1 resulting in a fall and injury. S2 received a counseling memo for the incident. S2 confirmed being with R1 and was assisting with transfer on 1/31/2020. R1 lost balance and they both fell onto the ground. S2 denied doing anything wrong during the transfer.

Medical records showed R1 was transported and treated at the hospital ER on 1/31/2020 at 12:41PM. R1 sustained bruised left hand and abrasion to right side forehead. No other injuries reported. R1 was discharged back to facility on the same date at 5:09PM hours.

During the course of the investigation, there was sufficient evidence to substantiate the allegation of Neglect/lack of care and supervision. S2 did not follow the facility’s training/procedure regarding transferring of resident. S2 improperly transferred R1 resulting in a fall and injury on 1/31/2020, the preponderance of evidence standard has been met, therefore the above allegations are substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator via tele-visit a copy of the report along with appeal rights was sent via email and an electronic email read receipt confirms receiving of the report. Administrator agrees to review, agrees to send the signed report via email.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200204080733

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: REGENCY, THE	FACILITY NUMBER: 306005350
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/17/2020 Section Cited CCR 87464(f)	1 2 3 4 5 6 7	87464(f) Basic Services shall at a minimum include: (1) Care and Supervision as defined in Section 87101(c)(3) and Health & Safety Code 1569.2(C)...This requirement is not met as evidenced by the complaint investigation where S2 improperly transferred R1 resulting in a fall and injury on 01/31/2020. This poses an immediate	1 2 3 4 5 6 7	Administrator states will conduct training in the area cited. Licensee will forward proof of correction to CCL by the due date of 09/18/2020.
	8 9 10 11 12 13 14	risk to the health & safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020

LIC9099 (FAS) - (06/04)

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