306005351-4-15-2021-22-AS-AORZ-C2NPTA-20210503113535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005351
Report Date: 04/15/2021
Date Signed: 04/15/2021 03:38:48 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
11/04/2020 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20201104131806

FACILITY NAME:	LA VIDA AT MISSION VIEJO		FACILITY NUMBER:	306005351
ADMINISTRATOR:	JUSTINE ORTIZ		FACILITY TYPE:	740
ADDRESS:	27783 CENTER DRIVE		TELEPHONE:	(949) 364-6210
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92692
CAPACITY:	150	CENSUS: 92	DATE:	04/15/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Justine Ortiz		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not follow the hospice plan.
Staff were isolating resident unnecessarily.
Staff did not notify responsible party of incidents.
Staff did not meet the needs of the resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry by Administrator Justine Ortiz and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as physician report, care plan, and hospice documentation. Regarding the allegations that staff did not follow the hospice plan, staff were isolating resident unnecessarily, staff did not notify responsible party of incidents and staff did not meet the needs of the resident, the investigation revealed the following: On 09/26/2021, Resident 1(R1) was found on the floor by care staff with bruising to upper side of face and grimacing. Facility called 911 per facility and licensing protocols. Hospice documentation dated 09/26/2021 indicates hospice agency was notified as well as responsible party. Paramedics responded and transferred R1 to the closest hospital, Mission Hospital. Per witnesses interviewed, R1's responsible party had previously requested R1 be sent to Saddleback Hospital for any necessary hospitalization's. However, responding paramedics determine which hospital the resident will be sent to. Upon R1's return to the facility, CONTINUED ON LIC 9099 DATED 04/15/2021

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

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 2

Control Number 22-AS-20201104131806

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: LA VIDA AT MISSION VIEJO	FACILITY NUMBER: 306005351
	VISIT DATE: 04/15/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R1 was put into quarantine for 96 hours pending a second negative covid test. At the time of complaint, OC Public Health was recommending a second negative covid test upon return from hospitalization due to the surge occurring. The facility was compliant with the recommendation from OC Public Health and placed R1 in isolation pending a second negative test. Per hospice documentation dated 09/11/2021-10/01/2021 as well as witness interviews, R1's responsible party was being updated weekly at a minimum regarding resident's status. Per interviews and hospice documentation, facility requested responsible party to hire a private caregiver to observe resident upon return from hospital. Responsible party declines to provide a private caregiver with expectation that facility will provide monitoring. Facility states R1 was being observed every 30-60 minutes by facility caregiver. R1 was found on the floor later that night. Hospice provided a one on one care companion that evening. Hospice documentation indicates R1 is incontinent, needs maximum assist with transfers and ambulation, and utilizes a wheelchair. R1 is under a pureed and nectar thick diet to prevent aspiration and had lost weight due to not eating and general decline. Facility states being in constant communication with responsible party and physician. R1 was moved to a board and care on 09/30/2021. Per hospice nurse interview and hospice notes dated 09/30/2021, R1 tolerated the transfer well to the new facility. R1 was assessed by nurse at the new facility and was noted to be lethargic but able to respond to stimuli. Therefore the allegations are deemed unfounded meaning the allegations are false could not have happened and/or is without a reasonable basis.

Exit interview conducted with Administrator and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2