306005755-3-8-2023-22-AS-SSAS-CPR4FM-20230308180411

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005755
Report Date: 03/08/2023
Date Signed: 03/08/2023 11:55:08 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
07/09/2021 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210709114351

FACILITY NAME:	SACRED HEART SENIOR CARE		FACILITY NUMBER:	306005755
ADMINISTRATOR:	ALDIANO, ANNA LIZA		FACILITY TYPE:	740
ADDRESS:	25602 WILLOW BEND		TELEPHONE:	(949) 600-7009
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Marebith Lupiba		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident has sustained unexplained weight loss do to lack of being fed
Staff are not meeting resident's needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst Michelle Reed arrived at the facility to deliver the findings of this complaint investigation. Upon arrival, LPA met with Administrator Marebith Lupiba. The complaint was investigated and consisted of interviews with the facility staff, Administrator and a review of Resident #1’s records. The following was determined:

R1 was admitted into the facility on 10/12/20. R1 had a history of stroke and muscle weakness. He was non-ambulatory and needed assistance with all his activities of daily living. R1 was receiving home health and physical therapy.

Three staff interviewed disclosed that R1 did eat, but would often forget that he ate. Staff interviewed stated that residents are served vegetables, protein(meat, fish) and ice cream. R1 stated that he does eat but that they were not feeding him the kind of food he likes like sushi and steak.

Staff were also asked about moving R1 from his bed. Staff stated that R1 had a hoyer lift that had just been

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

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-20210709114351

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: SACRED HEART SENIOR CARE	FACILITY NUMBER: 306005755
	VISIT DATE: 03/08/2023

NARRATIVE

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delivered, but it was hard to move him as he was contracted. They stated a special wheelchair had been ordered but that it was taking a long time to receive. At the time of LPA’s visit on 7/16/21, a physical therapist was conducting an evaluation for R1.

Administrator stated that R1 was conserved and the Conservator was aware of R1’s condition. On 11/11/21 R1 was taken to the hospital due to shaking on his left side. R1 was admitted for further evaluation. R1 returned to the facility under hospice services and passed away on 12/13/21.

Based upon a review of records and the interviews conducted the allegations are unfounded, meaning that the allegations are false, could not have happened and/or are without a reasonable basis. The Department has therefore dismissed the complaint.

An exit interview was conducted and a copy of this report was provided to Marebith Lupiba.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC9099 (FAS) - (06/04)

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