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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005773
Report Date: 09/08/2022
Date Signed: 09/08/2022 01:44:58 PM

Substantiated


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
08/23/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220823143206
FACILITY NAME:FAMILY CHOICE SENIOR LIVINGFACILITY NUMBER:
306005773
ADMINISTRATOR:HUNDLEY, SHANNONFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 12DATE:
09/08/2022
UNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Lakshmi JonnadaTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Facility has cockroaches
Administrator is yelling in front of residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Lakshmi Jonnada arrived during the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as extermination records. Regarding the allegations that facility has cockroaches and administrator is yelling in front of residents, the investigation revealed the following: Three out of three staff interviewed confirmed facility had roaches and extermination was provided by an outside company shortly before LPA's initial visit. LPA observed dead cockroaches in kitchen cupboards on initial visit and a live cockroach on second complaint visit. Three out of three staff interviewed confirm a verbal altercation between Administrator and Staff 1 (S1) in the common area. Administrator states a conversation with S1 over medication became heated and all interviewed confirm the conversation could be heard by residents. The preponderance of evidence standard has been met, therefore the above allegations are found to CONTINUED ON LIC 9099C DATED 09/08/2022.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
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 5
Control Number 22-AS-20220823143206
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: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306005773
VISIT DATE: 09/08/2022
NARRATIVE
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be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20220823143206
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: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306005773
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2022
Section Cited
CCR
87468.1(a)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by:
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Licensee to provide a written understanding of the regulation and forward to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure residents are accorded dignity at the facility. Three out of three staff interviewed confirm a verbal altercation between Administrator and S1 in front of residents. This poses a potential health and safety risk to residents in care.
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Type B
09/22/2022
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This req is not being met as evidenced by:
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Licensee to complete extermination of roaches/ insects as well as clean areas infested and forward proof to LPA by POC due date.
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Based on observation, Licensee failed to ensure facility is clean and sanitary. All staff interviewed confirm facility had roaches and LPA observed dead roaches as well as a live one on second visit to facility. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/23/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220823143206

FACILITY NAME:FAMILY CHOICE SENIOR LIVINGFACILITY NUMBER:
306005773
ADMINISTRATOR:HUNDLEY, SHANNONFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 12DATE:
09/08/2022
UNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Lakshmi JonnadaTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Facility does not have sufficient amount of staff to meet the resident's needs
Facility lack of supervision led to resident breaking her hip
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Lakshmi Jonnada arrived during the visit.

During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as staff schedule and physician report. Regarding the allegations that facility lack of supervision led to resident breaking the resident's hip and facility does not have sufficient amount of staff to meet the resident's needs, the investigation revealed the following: Three out of three staff interviewed confirm staffing shortages at the facility. Administrator indicates filling in as needed as well as agency usage. Facility provided a staff schedule for August 2022 indicating staffing agency caregivers for six shifts in August. Administrator confirms actively recruiting and LPA observed during visits that residents appear clean and taken care of. Staff state residents are being showered and cared for. On 8/18/2022, Resident 1 (R1) appeared to be in pain. Administrator had the resident assessed CONTINUED ON LIC 9099C DATED 09/08/2022
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20220823143206
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: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306005773
VISIT DATE: 09/08/2022
NARRATIVE
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by physician via zoom and physician noted no injuries. R1 was ordered Tylenol for pain with the caveat to contact physician the following day. R1 was sent out via 911 the following day for continued pain. Resident was diagnosed with hip fracture and subsequently had hip surgery. Staff and witness indicate R1 was ambulatory and not a fall risk. Witness states no visible injury on R1 and is still unsure how the fracture occurred. Staff deny resident fell. Due to conflicting information, LPA is unable to corroborate the allegation. 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 Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5