306005530-2-11-2021-22-AS-SSAS-C362NE-20210518173237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005530
Report Date: 02/09/2021
Date Signed: 02/11/2021 04:14:58 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
09/17/2020 and conducted by Evaluator Michael Barrett

COMPLAINT CONTROL NUMBER: 22-AS-20200917092907

FACILITY NAME:	VIVIDUS SENIOR LIVING		FACILITY NUMBER:	306005530
ADMINISTRATOR:	SHARIFAN, BAABAK		FACILITY TYPE:	740
ADDRESS:	25572 MAXIMUS ST		TELEPHONE:	(949) 584-0920
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	02/09/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator (AD) Bobby Sharifan		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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-Resident sustained unexplained bruising while in care.
-Facility staff did not notify resident's authorized representative of injuries

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mike Barrett initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted virtually with Administrator (AD), Bobby Sharifan. The following are the findings of the investigation conducted by LPA Barrett, which involved interviews, record review and site observations.

On September 17, 2020, the Department received a complaint alleging that the Resident sustained unexplained bruising while in care. It was reported that Resident #1 (R1) sustained bruising around his left eye as well as scattered bruising on his back. Per the LIC 624 (Physician’s Report) dated, 6/17/2020, R1 was diagnosed with myelodysplastic syndrome for which symptoms include easy or unusual bleeding which occurs due to low blood platelet count (thrombocytopenia). LPA also observed resident progress notes from Graybill Medical Group, dated 6/10/2020, listing bruising tendency as one of R1’s chronic conditions.
Continued on page 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021

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-20200917092907

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: VIVIDUS SENIOR LIVING	FACILITY NUMBER: 306005530
	VISIT DATE: 02/09/2021

NARRATIVE

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Continued from page 1.

Email communication from R1’s primary care physician addressed to the facility Administrator, home health agency and R1’s family addressed the bruising on R1’s body as common to someone on blood thinners, caused by low platelets. It was documented that R1 was prescribed and taking Metoprolol Succinate. Based on observation, interviews conducted, and documents reviewed, there is not enough evidence to show that a violation did or did not occur therefore, this allegation is deemed to be unsubstantiated.

It was also alleged that the facility staff did not notify resident’s authorized representative of injuries. It was reported that the bruising that was observed around R1’s left eye and back were not reported by the staff. LPA Barrett obtained copies of email correspondence with R1’s primary care physician dated between 9/16/2020 and 9/18/2020, referring to R1’s condition and discussing the lack of communication from the hospice company to the primary care physician and R1’s responsible party. Interviews were conducted with the Administrator and facility staff who stated that the bruising was reported to the hospice agency and that protocol for communication was followed and that it was the hospice agency’s responsibility to communicate with R1’s primary care physician and R1’s responsible party. Based on interviews conducted and documents reviewed, there is not enough evidence to show that the allegation did or did not occur therefore, it is deemed to be unsubstantiated.

This department has investigated this complaint. No violations are being cited at this time.

An exit interview was conducted with Administrator (AD) Bobby Sharifan via telephone and a hard copy of this report was provided via email for signatures.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Michael Barrett	TELEPHONE: (714) 703-2847
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021

LIC9099 (FAS) - (06/04)

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