306005672-2-21-2023-22-AS-LADS-CPS3GM-20230309171433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005672
Report Date: 02/21/2023
Date Signed: 02/21/2023 02:33:34 PM

Unsubstantiated

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
11/17/2022 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221117110159

FACILITY NAME:	WELLINGTON, THE		FACILITY NUMBER:	306005672
ADMINISTRATOR:	THOMAS, JOHNATHAN		FACILITY TYPE:	740
ADDRESS:	24903 MOULTON PARKWAY		TELEPHONE:	(949) 458-2311
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	160	CENSUS: 177	DATE:	02/21/2023
		UNANNOUNCED	TIME BEGAN:	01:11 PM
MET WITH:	Executive Director-Kathleen Olson		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not provide proper medication attention to resident.
Facility staff does not respond to resident’s call button.
Facility staff mismanaged resident’s medication.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver the findings for the complaint filed on 11/17/22. LPA was greeted by front desk staff and met with Executive Director (ED) Kathleen Olson, and LPA explained reason for visit.

For today's visit, there are a total of 104 residents in care, of which 8 are on hospice.

SEE LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

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-20221117110159

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: 02/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

This department has investigated the complaint alleging that facility staff did not provide proper medication attention to resident. LPA conducted interviews with clinical staff (med-techs, caregivers and nurses and the healthcare director), and residents. LPA also conducted record reviews such as, but not limited to: incident reports, resident’s care plan, resident’s progress notes, resident’s admission agreement, physician report, and staff schedules. It was found that if there is a medical emergency that takes place, 911 will be contacted to ensure that the resident receives the attention needed, of which was stated in interviews and indicated in incident reports. 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 the lack of evidence provided, and that there were no specified details indicated on documentation reviewed, regarding this allegation. 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; therefore, this allegation is deemed UNSUBSTANTIATED.

This department has investigated the complaint alleging that facility staff does not respond to resident’s call button. LPA conducted interviews with clinical staff (med-techs, caregivers, nurse, health director, and management), and residents, along with record reviews such as, but not limited to: incident reports, physician reports, staff schedule, and the facility pendent button log. Per record review and interviews, it was found that each resident has a call button and that staff will attend and respond to resident in no less than 20 minutes, however, the target response time is between 4-10 minutes. It was also stated that the facility has an alarm system that will notify all clinical staff, management, and front desk staff if a resident has pressed their call button. LPA also conducted a tour of the facility on 11/28/22, and tested random call buttons throughout the facility, all of which staff responded within a 4-7 minute time frame. 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; therefore, this allegation is deemed UNSUBSTANTIATED.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20221117110159

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: 02/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

This department has investigated the complaint alleging that facility staff mismanaged resident’s medication. LPA conducted interviews with clinical staff (med-techs, caregivers, nurse, health director, and management), and residents, along with record reviews such as, but not limited to: staff schedules, medication log, incident reports, physician reports, resident care plans, and progress notes. LPA found that facility nurses and/or med-techs are the individuals who assist with administering medications and vitamins and that clinical staff will not make any unauthorized changes to medications and its dosages unless the order has been verified by the resident’s physician. In addition, clinical staff will give medications to residents at the instructed time, but may administer it either 30 minutes before or after, however, not exceeding the 30-minute time frame. Specifically, this did not occur with the allegation indicated, due to the allegation stating that the facility administered the resident’s medication within a four hour time difference. 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 the lack of evidence provided, and that there were no specified details indicated on documentation reviewed, regarding this allegation. 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; therefore, this allegation is deemed UNSUBSTANTIATED.

For today's visit, no citations were issued, and no deficiencies were issued.

An exit interview was conducted with ED Olson and a copy of this report was given to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3