306005672-1-12-2023-22-AS-LADS-CN9QGR-20230120110957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005672
Report Date: 01/12/2023
Date Signed: 01/12/2023 11:03:57 AM

Unfounded

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
12/16/2020 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201216095338

FACILITY NAME:	WELLINGTON, THE		FACILITY NUMBER:	306005672
ADMINISTRATOR:	FAYE, SAM		FACILITY TYPE:	740
ADDRESS:	24903 MOULTON PARKWAY		TELEPHONE:	(949) 458-2311
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	160	CENSUS: 123	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	Sam Faye - Executive Director		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility did not safeguard resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings of the investigation into the above allegation. LPA Velazquez was allowed entry into the facility and met with Executive Director (ED) Sam Faye and explained the purpose of the visit.

On today’s visit LPA Velazquez conducted an interview with ED Faye. LPA Velazquez also requested facility and resident records. During the course of the investigation LPAs Joseph Alejandre and Patricia Velazquez conducted interviews with the complainant, residents, and staff. LPAs Alejandre and Velazquez also obtained facility, resident, and staff records. Records reviewed included Resident Admission Agreements, Physician Reports, Hospice Records, Medication Administration Records (MARs), Centrally Stored Medication and Destruction Records (CSMDRs), Resident Progress Notes, Individualized Service Plans, and Resident Summaries. The investigation revealed the following: Residents (R) #3 and #4 were admitted to the facility on

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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-20201216095338

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: WELLINGTON, THE	FACILITY NUMBER: 306005672
	VISIT DATE: 01/12/2023

NARRATIVE

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April 14, 2019. R3’s physician’s report with date of exam documented as February 4, 2019 indicated R3 could store and administer their own medications. R4’s physician’s report with date of exam documented as February 6, 2019 indicated R4 could store and administer their own medications. Facility records further indicated R3 and R4 were not receiving medication management services at the time of admission. R3 is alleged to have taken medication belonging to R4 at the time R3 and R4 were managing their own medications and not on medication management by the facility. Three of three individuals interviewed stated they never actually witnessed R3 consuming any of R4’s medication and could not corroborate the allegation. R3 further denied ever taking any of R4’s medications.

This agency has investigated the complaint and based on the above findings has determined the allegation: Facility did not safeguard resident's medication to be UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Executive Director Sam Faye and a copy of this report along with the LIC 811 was provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC9099 (FAS) - (06/04)

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