306005351-7-14-2021-22-AS-AORZ-C53NVS-20210719104823

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005351
Report Date: 07/14/2021
Date Signed: 07/14/2021 12:50:22 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
12/18/2020 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20201218162225

FACILITY NAME:	LA VIDA AT MISSION VIEJO		FACILITY NUMBER:	306005351
ADMINISTRATOR:	HEIDI CHARETTE		FACILITY TYPE:	740
ADDRESS:	27783 CENTER DRIVE		TELEPHONE:	(949) 364-6210
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92692
CAPACITY:	150	CENSUS: 97	DATE:	07/14/2021
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Justine Ortiz		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility staff handle residents in a rough manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman visited the facility for the purpose of delivering findings on a complaint investigatio. LPA identified herself and discussed the purpose of the visit and elements of allegation with Administrator Justine Ortiz.
During the course of the investigation, LPA toured the facility, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as Staff 1 (S1) training records, Resident 1 (R1) physician report, and R1 medication orders. Regarding the allegation that facility staff handle residents in a rough manner, the investigation revealed the following: Five out of eight residents interviewed confirm S1 is rough and hurried when providing caregiving. The former Administrator, Heidi Charrette, confirmed through interview that R1 reported that S1 had been rough with them. All residents interviewed state that they do not believe S1 is being intentionally rough but S1 just does not realize how strong the staff is. None of the residents interviewed stated a fear of the S1, just that the staff is hurried and rough when providing care. R1 requested a different caregiver and the facility complied with the request. Interviews with S1 indicate they were unaware of resident’s concerns CONTINUED ON LIC 9099 DATED 07/14/2021

Substantiated

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: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

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 5

Control Number 22-AS-20201218162225

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: 07/14/2021

NARRATIVE

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and states no intention to be rough. Two out of two caregivers interviewed indicated residents had reported to them that S1 was rough during caregiving. Training records provided to LPA indicate S1 received appropriate required training upon hire. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
An exit interview was conducted with Administrator Ortiz and a copy of this report, confidential names list and appeal rights was provided to Administrator.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 22-AS-20201218162225

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/15/2021 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by:	1 2 3 4 5 6 7	Licensee to forward proof of personal rights re-training to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted, Licensee failed to ensure residents are free from physical abuse. Five out of eight residents confirm S1 is rough during caregiving. This poses an immediate health and safety risk to 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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
12/18/2020 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20201218162225

FACILITY NAME:	LA VIDA AT MISSION VIEJO		FACILITY NUMBER:	306005351
ADMINISTRATOR:	HEIDI CHARETTE		FACILITY TYPE:	740
ADDRESS:	27783 CENTER DRIVE		TELEPHONE:	(949) 364-6210
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92692
CAPACITY:	150	CENSUS:	DATE:	07/14/2021
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:			TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility staff caused injury to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman visited the facility for the purpose of delivering findings on a complaint investigation LPA identified herself and discussed the purpose of the call and elements of allegation with Administrator Justine Ortiz.
During the course of the investigation, LPA toured the facility, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as Staff 1 (S1) training records, Resident 1 (R1) physician report, and R1 medication orders. Regarding the allegation that facility staff caused injury to resident, the investigation revealed the following: R1 reported to facility management that S1 caused pain to resident while putting on an orthotic boot as well as bruising on the arm. Interview with R1 confirms the report. R1 states S1 is rough with caregiving but does not believe the staff is intending malice. During the visit, LPA observed light bruising on R1’s upper arm. R1 is on blood thinner Eliquis, prescribed as 2.5MG two times a day. Per Eliquis patient warning, users of Eliquis may have side effects of increased or unexpected bleeding. S1 denies causing any injury to R1. There is no facility documentation of injury other than a written transcript of interview with CONTINUED ON LIC 9099C DATED 07/14/2021

Unsubstantiated

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: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

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 5

Control Number 22-AS-20201218162225

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: 07/14/2021

NARRATIVE

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S1 regarding the incident. Due to conflicting information, LPA is unable to corroborate allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
An exit interview was conducted with Administrator Ortiz and a copy of this report, confidential names list and appeal rights was provided to Administrator.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5