306005720-9-3-2023-22-AS-AORZ-CVNUVF-20230914155505

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005720
Report Date: 09/03/2023
Date Signed: 09/03/2023 03:39:35 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
01/11/2021 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210111133636

FACILITY NAME:	HOME SWEET HOME RESIDENTIAL CARE		FACILITY NUMBER:	306005720
ADMINISTRATOR:	LUU, CHI V		FACILITY TYPE:	740
ADDRESS:	362 N SWIDLER STREET		TELEPHONE:	(714) 785-9555
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	0	CENSUS: 0	DATE:	09/03/2023
		UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Chi Luu, Administrator		TIME COMPLETED:	03:38 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Resident sustained injuries from multiple falls while in care

INVESTIGATION FINDINGS:

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

On today's date, Licensing Program Analyst (LPA), LPA Rosie Quiroz contacted Administrator (AD) Chi Luu via telephone for the purpose of delivering findings of the complaint investigation allegation listed above. LPA Quiroz identified herself and discussed the findings with AD Chi Luu.
On January 11, 2021, the Department received a complaint alleging that the "resident sustained injuries from multiple falls while in care." LPA Lyman conducted a virTual 10 day visit on 1/20/2021 due to COVID-19 precautionary measures.
During the course of the investigation, the investigation revealed the following: Resident 1 (R1) entered hospice on 11/22/2020. Investigations with two of two interviewees revealed (R1) was prescribed a right prosthetic arm and would refuse to wear it. Two of two interviewees indicated (R1's) Primary Care Physician (PCP) was aware of (R1) refusing to wear right arm prosthetic arm indicating being informed by (R1s) PCP possibility of inbalance due to not wearing prosthetic right arm causing in balance with motor skills and equilibrium. Two of two interviewees indicated (R1) had ex military background and would often swing left arm in the air followed by property destruction. CONTINUED ON LIC 9099-C PAGE...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2023

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 2

Control Number 22-AS-20210111133636

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: HOME SWEET HOME RESIDENTIAL CARE	FACILITY NUMBER: 306005720
	VISIT DATE: 09/03/2023

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

CONTINUED...
Based on the information gathered through interviews and documentation obtained and reviewed; there was no evidence to corroborate the allegation of the resident sustaining injuries from multiple falls while in care. The allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with (AD) Chi Luu. A copy of this report will be provided via email. (AD) Chi Luu agreed to confirm the receipt of the document, review the report and returned a signed copy.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2