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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005350
Report Date: 04/10/2023
Date Signed: 04/10/2023 11:43:58 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
07/06/2021 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210706093236
FACILITY NAME:REGENCY, THEFACILITY NUMBER:
306005350
ADMINISTRATOR:HEIDI CHARETTEFACILITY TYPE:
740
ADDRESS:24441 CALLE SONORATELEPHONE:
(949) 830-8057
CITY:LAGUNA WOODSSTATE: CAZIP CODE:
92637
CAPACITY:220CENSUS: 121DATE:
04/10/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Elena Madsen, Executive Director
Danielle Hauseman, Business Manager		TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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• Resident sustained a fracture while in care.
• Staff did not share accurate details with the resident representative.
• Resident had an unexplained injury.
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 arrived at facility and was greeted by Danielle Hauseman, Business Manager and granted entry. LPA spoke with Danielle Hauseman, Business Manager and explained the purpose of the visit. Elena Madsen, Executive Director arrived shortly after and met with LPA.

The complaint was investigated by Community Care Licensing Investigations Branch (IB). Findings are based upon this investigation which included file review, interviews with the following: multiple 9 out of 9 staff and witnesses, medical records from Memorial Care Saddleback Medical Center, and Long Beach Memorial Medical Center.


Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 22-AS-20210706093236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: REGENCY, THE
FACILITY NUMBER: 306005350
VISIT DATE: 04/10/2023
NARRATIVE
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It is alleged that resident sustained a fracture while in care. The investigation did not produce substantial evidence to support that R1 had a fracture while in care or unexplained injury. It could not be determined whether R1’s fall was an assisted fall or not. The sole caregiver who was present with R1 and assisted was interviewed and maintains the fall was assisted. Interview with witness (W2) stated if R1 was reporting no pain, during the service call there no obvious signs of any type of fracture. Medical records from Memorial Care Saddleback Medical Center emergency note indicate per staff R1 had an unwitnessed fall sometime last week – exact date unknown prior to 06/23/2021 incident. 911 was initiated but transportation was refused by family. No evidence of abuse/neglect noted on medical records. There are no other contributing witnesses to the fall. Therefore; the are no statements obtained to contradict the caregiver’s report.

It is alleged that staff did not share accurate details with the resident’s representatives. Records review reflect written statement from S2 revealed that on 06/23/2021 at approximately 9:18am S9 and S2 called to speak to resident’s daughter but she was unavailable according to her husband. S2 and S9 informed the resident’s son-in-law about the incident. It was explained that an agency caregiver S3 stated that while attempting to transfer resident from wheelchair to shower chair, resident yelled “this is too hard, I can’t do this” and began to buckle. S3 stated that resident was assisted down to the floor, noting that resident’s right leg was crossed over her left leg. Caregiver also stated that S3 supported the resident’s back with their leg and arms while resident was on the floor. S3 then attempted to get resident back up and into the wheelchair twice before calling for assistance. S7 arrived to the apartment and noted that resident was on the floor and that she was being supported by S3. Resident was assisted back into the wheelchair and transferred to bed. After discussing the incident with resident’s son-in-law, he indicated no to send the resident out. At approximately 10:57am daughter of R1 called facility requesting information regarding the incident. Daughter was given the same information as to her husband on the previous call. Interview with W1 revealed they were notified about incident with the information that facility staff had at the time.

It is alleged that resident had an unexplained injury. Records review revealed that progress notes for R1 on 06/16/2021 at 1:01pm resident was found with a discoloration on her right forehead this morning and on duty was notified and 911 was called for resident to get evaluation. R1 refused to go to the hospital. Progress notes also revealed that on 06/22/2021 at 6:13am that resident had a red spot in head so and staff went to R1’s

Continued on LIC9099-C
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20210706093236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: REGENCY, THE
FACILITY NUMBER: 306005350
VISIT DATE: 04/10/2023
NARRATIVE
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apartment and found R1 in bed with a big red spot in head, that had not been seen before. 911 was called and the paramedics arrived and got a verbal consent from R1 to not go to the ER. Interview with S2 revealed that a
911 call had been made on 06/16/2021 due to mark or bruise found in R1’s forehead. S2 indicated they believed R1 may have gotten the mark on forehead form the bedrails on the bed. S2 stated “bedrails are known to cause marks onto residents as they hit themselves onto the bedrails while moving around on their bed." S2 believe that bedrails may have been used as leverage bars to pull themselves in their beds for positioning but can bump their heads on the rails in the process. Interview with S5 revealed that discoloration and spots were found on R1’s forehead. S5 stated R1 would become combative, restless, and agitated. S5 believes R1 may had hit the head onto the bedrails.

Based on the information gathered during the investigation, interviews and review of all documents obtained, the Department is unable to ascertain if the allegation 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, this allegation is deemed Unsubstantiated.

An exit interview was conducted with facility representatives, and a copy of this LIC9099 report was left at facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
07/06/2021 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210706093236

FACILITY NAME:REGENCY, THEFACILITY NUMBER:
306005350
ADMINISTRATOR:HEIDI CHARETTEFACILITY TYPE:
740
ADDRESS:24441 CALLE SONORATELEPHONE:
(949) 830-8057
CITY:LAGUNA WOODSSTATE: CAZIP CODE:
92637
CAPACITY:220CENSUS: 121DATE:
04/10/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Elena Madsen, Executive Director
Danielle Hauseman, Business Manager		TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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• Staff did not obtain medical care for the resident in a timely manner.
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 allegation. LPA arrived at facility and was greeted by Danielle Hauseman, Business Manager and granted entry. LPA spoke with Danielle Hauseman, Business Manager and explained the purpose of the visit. Elena Madsen, Executive Director arrived shortly after and met with LPA.

The complaint was investigated by the Department. Findings are based upon this investigation which included records review, interviews with the following: 9 out of 9 staff interviewed, and witnesses, medical records from Memorial Care Saddleback Medical Center, and Long Beach Memorial Medical Center.

It is alleged that staff did not obtain medical care for resident in a timely manner. The investigation revealed a

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20210706093236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: REGENCY, THE
FACILITY NUMBER: 306005350
VISIT DATE: 04/10/2023
NARRATIVE
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lack of communication amongst 9 out of 9 facility staff who were present when the alleged assisted fall occurred and immediately thereafter on June 23, 2021 which appeared to have contributed to causing a delay in contacting 911 emergency services and providing timely required medical care. The assisted fall incident occurred at approximately at 7:00AM to 7:30AM and 911 was contacted at 11:33AM. The time between the incident and the call was approximately 4 hours to 4.5 hours delayed according to Orange County Fire Department records dated 06/23/2021. Records review revealed statement from staff (S2) revealed that they received a call at 8:02am from S5 stating there is an emergency at the community. Resident (R1) was dropped on the floor by the agency caregiver. S2 asked S5 for details and informed them that S2 was 20 minutes away. At approximately 8:45am S2 along with S8 went to resident’s apartment to assess the injury. At 9:18am S2 and S9 called resident’s daughter and was unavailable and staff informed son-in-law about the incident. As to son-in-law indicated to not send the resident out to be evaluated. At 10:57am S2 received a call from resident’s daughter requesting information about incident. Daughter indicated that resident was not to go to the hospital or have 911 called. At approximately 11:05am S2 went to check on resident and immediately noted the following increased swelling in the right knew and thigh along with what appeared to be shortening of the resident’s right leg. S2 requested the assistance of S6 Regional Nurse to assess the residents to determine the need for further evaluation. 911 was called and at 11:33am paramedics arrived. Furthermore, statements obtained through 9 out of 9 staff interviews indicated that facility staff were concerned over contacting 911 in anticipation or receiving objection’s from R1’s responsible party, which contributed to the delay of contacting medical services.

During the course of the investigation, there was sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted with facility representatives and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) and LIC811 left at facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20210706093236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: REGENCY, THE
FACILITY NUMBER: 306005350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2023
Section Cited
CCR
87465(g)
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The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...This requirement is not met as evidence by: The "assisted" fall incident occured at approximately at 7:00AM to 7:30AM and 911
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Facility will conduct In-Service training pertaining to Section 87465(g) and develop a plan to ensure immediate medical assistance is provided to all residents. An outline of the plan is to be submitted to the licensing office by POC due date.
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was contacted at 11:33AM. The time between the incident and the call was delayed approximately 4 hours to 4.5 hours according to Orange County Fire Department records dated 06/23/2021. This poses an immediate risk to the health & safety of the resident in care.
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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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6