306005796-1-6-2023-22-AS-SSAS-CMZ4DM-20230111180058

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005796
Report Date: 01/06/2023
Date Signed: 01/06/2023 02:34:54 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
12/29/2022 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221229161124

FACILITY NAME:	ACTIVCARE ORANGE		FACILITY NUMBER:	306005796
ADMINISTRATOR:	LEDESMA, ELVA		FACILITY TYPE:	740
ADDRESS:	2629 E. CHAPMAN AVENUE		TELEPHONE:	(714) 215-9944
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	72	CENSUS: 22	DATE:	01/06/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Vanessa Valencia		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained injuries due to lack of care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)Michelle Reed arrived at the facility to discuss the complaint allegation. Upon arrival, LPA met with Executive Director Vanessa Valencia. LPA toured the physical plant with Mrs. Valencia. Records were reviewed and interviews were also conducted.

Resident #1(R1) was admitted into the facility on 10/17/22. Records reviewed disclosed that R1 was nonambulatory with Dementia. R1 also had aggressive behavior, sundowning and needed assistance with all ADL's. The narrative charting as well as staff interviewed disclosed that R1 was often agitated and aggressive towards staff and other residents. R1 was able to walk through the building but had very unstable gait and did have falls with bruising. R1 was also very difficult to redirect. Facility staff reached out to R1's doctor and responsible party and medication adjustments were made. R1 also had a 1:1 companion in place, during the day, to assist with behaviors. Based upon interviews conducted and records reviewed the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that R1 sustained injuries due to lack of care. An exit interview was conducted with Vanessa Valencia and a copy of this report was provided.

Unsubstantiated

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: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

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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