306005446-6-12-2020-22-AS-MSTC-BQPRX5-20200618132406

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005446
Report Date: 06/11/2020
Date Signed: 06/12/2020 10:47:45 AM

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
02/27/2020 and conducted by Evaluator Shobhana Frank

COMPLAINT CONTROL NUMBER: 22-AS-20200227125231

FACILITY NAME:	KIRKWOOD ORANGE		FACILITY NUMBER:	306005446
ADMINISTRATOR:	ALETA WALKER		FACILITY TYPE:	740
ADDRESS:	1525 E TAFT AVE		TELEPHONE:	(714) 282-1409
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	65	CENSUS: 49	DATE:	06/11/2020
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Tele visit -Executive Director Aleta Walker		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Staff did not shower resident
Medications not given on time
Staff not meeting residents toileting needs
Toxins accessible to resident
Staff did not notify responsible person of change in resident's condition
Staff did not keep residents room clean
Resident's responsible person did not receive the new level change reassessment documentation to sign

INVESTIGATION FINDINGS:

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As precautionary health measures during the current public health crisis, Licensing Program Analyst (LPA) Shobhana Frank conducted a teleconference call with Executive Director Aleta Walker. LPA explained the purpose of this call; and the allegation described in this complaint was filed against the facility on March 8, 2020.
During the visit on 3/5/20, LPA conducted interview with Exicutive Director, Asisstant Administrator and requested copies of document related to the complaint. A copy of Shower Schedule, room cleaning schedule, Admission agreement dated 12/6/2019. A copy of LIC 602 Physician report dated 12/6/2019, initial assessment dated 12/4/2019, Service Plan. On 1/3/2020, modified Service Plan and on 1/17/2020, Medication Administration Record dated 12/4/19 to 3/1/2020.
Investigation into allegations bellow revealed the following:
1 Staff did not shower resident
Based on the reviewed of Shower Schedule dated 2/1/20 indicates that R 1 was showered as scheduled.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020

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-20200227125231

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: KIRKWOOD ORANGE	FACILITY NUMBER: 306005446
	VISIT DATE: 06/11/2020

NARRATIVE

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2 Medications not given on time.
Reviews of Medication Administration Record dated 12/4/19 to 3/1/20 indicates that R 1 was administered her medication as physician’s order.
3 Staff not meeting resident’s toileting needs
Interviews of S1 and ED and reviews of daily notes indicates that R 1’s toileting needs were met as required.

Also,ED reported that R 1’s daughter never complained that her mother’s toileting needs are not met.

4 Toxins accessible

Interviews of Housekeeper raveled that he never took furniture polish to R 1’s room. Also, daughter never reported to ED having a furniture polish in R 1’s room. A did not find any notes that indicates that room # 13 furniture was polished between 12/4/19 to 3/1/20.

5 Staff did not notify responsible person of change in resident's condition

ED stated that R 1 had diarrhea on 2/7/2020, 2/8/2020 and 2/9/2020. Daughter was informed via telephone.

Ed said that she had given her personal cell phone number to R 1’s daughter so she can be in touch with her mother. R 1’s daughter called Ed Aleta almost every other day. She was updated every other day regarding her mother’s health.

6 Staff did not keep residents’ room clean

Review of Housekeeping Schedule dated 3/1/20 indicates that resident’s room 13 was being clean every Friday as scheduled.

7 Resident's responsible person did not receive the new level change reassessment documentation to sign

Interview of ED reveled R 1’s daughter was informed via telephone as every other day daughter was calling on AD’s personnel cell phone.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200227125231

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: KIRKWOOD ORANGE	FACILITY NUMBER: 306005446
	VISIT DATE: 06/11/2020

NARRATIVE

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LPA interviewed R 1’s daughter who said she was very upset because her mother was sick and her mother’s fund was getting less, and it was hard for her to afford her mother’s monthly payment. She said that there are staff at the facility they went out of their way and helped her. There was no issue, she doesn’t want to investigate the complaint as there was only miss understating, and nothing to complain against the facility. A copy of refund check dated 6/3/2020 was provided by the facility. Based on interviews and reviews of document all Allegations are determined to be Unfounded.

The investigation into allegations of Staff did not shower resident, Medications not given on time, Staff not meeting resident’s toileting needs, Toxins accessible to resident, Staff did not notify responsible person of change in resident's condition, Staff did not keep residents’ room clean, Resident's responsible person did not receive the new level change reassessment documentation to sign, are deemed Unfounded. This agency has investigated allegations and are found to be Unfounded, meaning the allegations were false, could not have happened or/are without a reasonable basis. Therefore, the allegations are dismissed.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020

LIC9099 (FAS) - (06/04)

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