306005713-7-23-2021-22-AS-SSAS-C653GS-20210821181447

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005713
Report Date: 07/23/2021
Date Signed: 07/23/2021 05:44:17 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
10/23/2020 and conducted by Evaluator Kathrina Chin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201023161242

FACILITY NAME:	B&C SENIOR LIVING		FACILITY NUMBER:	306005713
ADMINISTRATOR:	ESTORBA, BRIAN		FACILITY TYPE:	740
ADDRESS:	10269 CLAUDIA AVE		TELEPHONE:	(714) 488-8413
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS: 6	DATE:	07/23/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Brian Estorba, Administator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident developed a Stage 4 pressure injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kathrina Chin made an unannounced visit to the facility for the purpose of presenting the findings of the complaint investigation. Upon arrival, LPA met with Administrator, Brian Estorba. The investigation consisted of interviews with the facility Administrator and witnesses as well as reviewing and obtaining documentation. The following was determined

Resident 1 was admitted to the facility on 7/14/2020 and resident was already on Green Meadows hospice upon admission Resident was admitted to the facility with a Stage II pressure injury on her right hip as indicated on the physician report dated 7/13/2020. Resident was placed on hospice due to heart disease. R 1's family changed the hospice agency to Americare Hospice on 7/18/2020. Mr. Estorba reported that R1 was receiving wound care from a wound care doctor from Americare Hospice. Mr. Estorba further explained that R1 was shivering on 10/21/2020 and the hospice agency sent out the resident by ambulance to Adventist Health White Memorial Hospital as requested by the family. (Continued on LIC 9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

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-20201023161242

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: B&C SENIOR LIVING	FACILITY NUMBER: 306005713
	VISIT DATE: 07/23/2021

NARRATIVE

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R1's family wanted to send out R1 to the hospital so R1 could be admitted to a Skilled Nursing Facility for daily wound care.

LPA , Kathrina Chin interviewed R1's responsible party and she stated that she was happy with the care that her R1 received at the facility and happy with the care provided by the hospice agency.

This agency has investigated the complaint and is determined 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, and a copy of this report was given to Brian Estorba, Administrator.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC9099 (FAS) - (06/04)

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