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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005446
Report Date: 02/17/2021
Date Signed: 02/17/2021 11:21:57 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
05/29/2020 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200529132951
FACILITY NAME:KIRKWOOD ORANGEFACILITY NUMBER:
306005446
ADMINISTRATOR:ALETA WALKERFACILITY TYPE:
740
ADDRESS:1525 E TAFT AVETELEPHONE:
(714) 282-1409
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:0CENSUS: 0DATE:
02/17/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Lack of supervision resulting in resident sustaining multiple falls
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michelle Reed mailed a copy of this report to MSL Community Management; 525 E Taft-Operator LLC. The purpose was to issue the findings of this complaint investigation. This facility changed ownership on 8/12/20 and was closed. The Licensee is no longer licensed at this address. Records were reviewed and interviews were conducted. R1 was admitted into the facility on 1/21/19. According to R1’s signed skilled nursing paperwork dated 1/3/19, it states “Based on an assessment, you are at risk of falling. You must obtain assistance to stand or walk.” Kirkwood’s Preplacement Appraisal dated 1/18/19 states R1 is a “balance and fall risk.” R1’s physician report dated 1/17/19 states, “ambulatory w/assistance on one side.” Daily logs reviewed for R1 disclosed that during the nine months R1 lived at the facility from 1/21/19 to 10/29/19, R1 had 25 documented falls. Eight of the falls resulted in 911 calls and 3 hospital visits with injuries.
Based upon interviews and records reviewed, the preponderance of evidence standard has been met therefore the above allegation is found to be SUBSTANTIATED.
See LIC9099D for cited deficiency per Title 22, Division 6, of the California Code of Regulations.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
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 3
Control Number 22-AS-20200529132951
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/11/2021
Section Cited
CCR
87464(f)(1)
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Basic Services- Basic services include: Care & supervision as defined in Section 87101(c)(3) and HS Code section 1569.2(c). Care & supervision means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living which the resident's physical, health, mental health, safety or welfare would be
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Facility closed on 8/12/20
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endangered. This requirement was not met as evidenced by: Per investigation, Licensee accepted R1 into facility knowing that R1 was a balance, fall risk. Staff did not provide assistance & adequate supervision for R1 as identified in R1’s pre-admission paperwork resulting in 25 documented falls within a nine month period.
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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: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
05/29/2020 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200529132951

FACILITY NAME:KIRKWOOD ORANGEFACILITY NUMBER:
306005446
ADMINISTRATOR:ALETA WALKERFACILITY TYPE:
740
ADDRESS:1525 E TAFT AVETELEPHONE:
(714) 282-1409
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:0CENSUS: DATE:
02/17/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Facility staff neglect resulting in resident sustaining an infected wound
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michelle Reed mailed a copy of this report to MSL Community Management; 525 E Taft-Operator LLC. The purpose was to issue the findings of this complaint investigation. This facility changed ownership and was closed on 8/12/20. The Licensee is no longer licensed at this address. Daily Logs were reviewed for R1 and interviews were conducted. R1 was admitted into the facility on 1/21/19. On 10/2/19 R1 fell. The fall resulted in a hospital visit for a skin tear to R1’s leg. When R1 returned from the hospital, home health was started by Care Dimensions Home Health to treat the skin tear. Care Dimensions visited twice a week beginning 10/4/19. On 10/7/19 facility staff noted a change in the injury and contacted the home health agency. R1 was sent to a skilled nursing facility on 10/29/19 by Care Dimensions for further treatment of her leg.

Based upon interviews and records reviewed, this allegation is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the facility staff neglected R1’s skin tear as home health was visiting twice a week.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3