306005745-8-13-2021-22-AS-AORZ-C6EUS3-20210831154937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005745
Report Date: 08/13/2021
Date Signed: 08/13/2021 08:57:55 AM

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
12/23/2020 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20201223111644

FACILITY NAME:	IRVINE COTTAGE #5		FACILITY NUMBER:	306005745
ADMINISTRATOR:	WALTERS, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	2 BRANDYWINE		TELEPHONE:	(949) 653-6114
CITY:	IRVINE	STATE: CA	ZIP CODE:	92620
CAPACITY:	6	CENSUS: 6	DATE:	08/13/2021
		UNANNOUNCED	TIME BEGAN:	08:43 AM
MET WITH:	Christina Lodevico		TIME COMPLETED:	09:17 AM

ALLEGATION(S):

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Resident developed pressure injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry by Caregiver Christina Lodevico and explained the reason for the visit.

LPA Trinidad initiated the complaint investigation as well as interviewed staff and residents. During the course of the investigation, LPA Lyman interviewed staff and residents as well as reviewed and obtained pertinent documentation such as facility notes and home health medical records. Regarding the allegation that resident developed pressure injuries while in care, the investigation revealed the following: Resident 1 admitted into the facility in September 2020 without any evidence of pressure injury. Upon return from hospitalization for a gastrointestinal bleed November 30, 2020, witnesses indicate R1 was noted to have a blister to right heel. Facility notes indicate instructions were given to staff to continue repositioning and off-loading the heel. R1 was referred to Care Plus Home Health and admitted for care on 12/04/2020. Home health records indicate R1 was experiencing a CONTINUED ON LIC 9099C DATED 08/13/2021

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

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-20201223111644

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: IRVINE COTTAGE #5	FACILITY NUMBER: 306005745
	VISIT DATE: 08/13/2021

NARRATIVE

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"Decline in mental, emotional or behavioral status in the last three months" as well as an admitting diagnosis of muscle weakness, blister on on right heel, and Alzheimer's Disease unspecified. Per home health records, R1 was noted to have a stage 2 pressure sore on coccyx on 12/10/2020 as well as a new sore on left foot on 12/17/2020. R1 was being seen continuously by home health for wound care and physical therapy. Home health documentation indicates R1 did not have any wounds prior to hospitalization in November 2020. Facility documentation as well as home health documentation indicated R1 was declining with fatigue and poor appetite. R1 was transferred to the hospital on 12/18/2020 with fatigue, swollen leg, and a low grade temperature. R1 subsequently passed away in February 2021. While the resident did obtain pressure injuries while in care, resident was being seen and treated by home health for the condition. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
An exit interview was conducted with Caregiver and a copy of this report and confidential names was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC9099 (FAS) - (06/04)

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