306005368-6-1-2023-22-AS-AORZ-CSUPFS-20230616111714

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005368
Report Date: 06/01/2023
Date Signed: 06/01/2023 12:14:09 PM

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
09/07/2021 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210907144011

FACILITY NAME:	SANTA AVILA CARE VILLA		FACILITY NUMBER:	306005368
ADMINISTRATOR:	ALIPIO, DIVINA JOY M.		FACILITY TYPE:	735
ADDRESS:	5501 MEINHARDT RD		TELEPHONE:	(714) 606-1087
CITY:	WESTMINISTER	STATE: CA	ZIP CODE:	92683
CAPACITY:	4	CENSUS: 4	DATE:	06/01/2023
		UNANNOUNCED	TIME BEGAN:	10:32 AM
MET WITH:	Leidenne Bueno-Caregiver, Divina Joy Alipio-Administrator		TIME COMPLETED:	12:29 PM

ALLEGATION(S):

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Client sustained multiple bruises on different parts of the body

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on 09/07/21. LPA was greeted and granted entry into the facility and initially met with Caregiver Leidenne Bueno. LPA explained the reason for the visit. Administrator (AD) Divina Joy Alipio arrived shortly after.

This agency has investigated the complaint alleging that Client sustained multiple bruises on different parts of the body. During the investigation documents reviewed included the Identification and Emergency Information (LIC601) date unknown. Per Identification and Emergency Information Resident 1 (R1) was admitted to the facility on 04/09/18. Records reviewed included the Physician Report (LIC602A) dated 06/23/21 for R1. Per Physician Report R1’s diagnoses are Epilepsy, Seizure Disorder, Behavior Breakdown and Pancytopenia. Records reviewed included the Unusual Incident/Injury Report (UIR) dated 09/02/21 for R1.
Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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-20210907144011

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: SANTA AVILA CARE VILLA	FACILITY NUMBER: 306005368
	VISIT DATE: 06/01/2023

NARRATIVE

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Per UIR R1’s lab results were received on 09/01/21 stating that R1’s plateles were low due to her diagnosis of Pancytopenia. Per Huntington Beach Hospital lab results dated 09/01/21 the White Blood Cell (WBC) and the Red Blood Cell (RBC) value for R1 were below Reference Range.

During the course of the complaint The Department conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Five of seven individuals interviewed denied the allegation. As for the remaining two individuals, one individual confirmed the allegation and the other did not return the call. Records reviewed included the Santa Avila Care Villa NOC Shift Notes dated 08/07/21-08/26/21 for R1. Per NOC Shift Notes R1 was monitored throughout the night as R1 often slides off their bed and dives into the floor. It was reported via interviews that on 09/01/21 R1 was noted to be pale and appeared tired. Per UIR R1 was transported to the Emergency Room on the evening of 09/01/21. During the course of the interviews AD stated that the symptoms of Pancytopenia can include bleeding, easy bruising, fatigue, shortness of breath and weakness. Records reviewed included Appraisal/Needs and Services Plan dated 08/01/21 for R1. Per Appraisal/Needs and Services Plan R1 wears a protective helmet and knee pads due to ataxia and history of falls…has no safety awareness when agitated and on behavior breakdown. It was reported via interviews by R1’s Physician that R1 has been diagnosed with Idiopathic Thrombocytopenic Purpura (ITP). The Mayo Clinic defines ITP as unusually low levels of platelets, the cells that help blood cloth. Per R1’s Physician the symptoms of ITP are easy bruising, extreme bleeding, bleeding from gums and nose, blood in urine and stools and unusually heavy menstrual flow. It was reported via interviews that it is common to see bruises for R1 in different stages of healing and that staff will document bruising on body check forms.

Although resident sustained bruises while in care the investigation could not conclude if the bruising was due to neglect. It remains unclear at this time if the bruising was as a result of the client’s self-injured behavior or if it was caused by facility staff.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Therefore, the allegations have been deemed to be UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred.

LPA Ramirez conducted an exit interview with AD Alipio, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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