306005798-5-17-2022-22-AS-LADS-CLVNU3-20221207094538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005798
Report Date: 05/17/2022
Date Signed: 05/17/2022 01:43:23 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
01/31/2022 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220131170149

FACILITY NAME:	PARK VIEW ESTATES		FACILITY NUMBER:	306005798
ADMINISTRATOR:	HEATHER MYERS		FACILITY TYPE:	740
ADDRESS:	11360 WARNER AVE.		TELEPHONE:	(949) 333-3486
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	150	CENSUS: 78	DATE:	05/17/2022
		UNANNOUNCED	TIME BEGAN:	11:54 AM
MET WITH:	Richard Mariona, Health Service Director and Sheila Fike, Executive Director		TIME COMPLETED:	12:47 PM

ALLEGATION(S):

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Resident sustained multiple falls with consequential rib fractures.

INVESTIGATION FINDINGS:

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On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose of delivering findings on a complaint investigation. During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation. Regarding the allegation that a resident sustained an injury due to falls with consequential rib fractures; the following was concluded:
The investigation revealed that Resident 1 (R1) who is diagnosed with Alzheimer’s and Dementia was admitted to the facility on 1/21/2022. (R1) was assessed by facility Memory Care Director and was approved to reside in the Memory Care Section. (R1) is ambulatory and walks with assistance of a walker and was assessed by Memory Care Director for potential falls based on the fall assessment dated 12/10/2021, and required fall monitoring.

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Substantiated

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: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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-20220131170149

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: PARK VIEW ESTATES	FACILITY NUMBER: 306005798
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely Type A 05/18/2022 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services-87464(f)(1):Basic Services at a minimum shall include care and supervision. Care and supervision means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety CONTINED...	1 2 3 4 5 6 7	Licensee agrees to provide ongoing assistance to residents who need assistance with their activities of daily living. The assistance shall be provided to ensure that the residents physical health, mental health, safety and welfare are not endangered. This assistance will include providing more staff as needed to meet the needs of all residents.Certification will be provided by the Licensee as proof of understanding of this subsection by POC due date of 5/20/22.
	8 9 10 11 12 13 14	or welfare would be endangered. This requirement was not met as evidenced by: On 1/12/22, Memory Care Director assessed (R1) for potential falls based on the fall assessment dated 12/10/21, and required fall monitoring. The facility staff failed to accurately assess and provide timely medical treatment for (R1). CONTINUED...	8 9 10 11 12 13 14	During duration period of 1/21/22-1/24/2022, (R1) resulted in three documented falls. While hospitalized at Fountain Valley Hospital, Dr. David Hamilton, MD diagnosed (R1) with fractured ribs from the fifth to the eight rib on the left side, weakness head injury and pneumonia.
Request Denied: Appeal Not Submitted Timely Type A 05/18/2022 Section Cited CCR 87705(c)(4):	1 2 3 4 5 6 7	Care of Persons with Dementia 87705(c)(4). There is an adequate number of direct care staff to support each resident’s physical…safety and health care needs as identified in his/her current appraisal This requirement was not met as evidenced by: Based on interviews, the facility failed to CONTINUED...	1 2 3 4 5 6 7	Facility agrees to ensure that all staff follow protocols to meet and support the needs of the residents in care. ED agreed to instruct all staff to review each resident's care plan to ensure that all safety needs are met. ED will conduct in service training about Dementia care and safety to all facility staff. Proof of correction will be provided to CCLD by POC due date of 5/20/22.
	8 9 10 11 12 13 14	ensure that facility staff follow protocol to support each resident’s physical, safety and health care needs as identified in current appraisal. The facility failed to have appropriate supervision to ensure that (R1) was observed and provided timely medical treatment after reported falls. Interviewees reported CONTINED...	8 9 10 11 12 13 14	facility to be understaffed with little to no supervision on the weekends or evenings allowing for Caregivers and Medication Technicians to manage the facility. The facility failed to take preventative measures to decrease the risk for falls for (R1).

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 Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220131170149

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: PARK VIEW ESTATES	FACILITY NUMBER: 306005798
	VISIT DATE: 05/17/2022

NARRATIVE

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Continued...
On 1/21/2022, (R1) was admitted to the facility late afternoon and was accompanied by his family with no reported incident documented by staff for that day. On 1/22/2022, at about 0515 hours, overnight staff found (R1) on his side next to the bed. Med Tech 1 (MT1) assessed (R1) for injury and reported “None found.”(R1) was not able to report how he fell. On 1/22/2022, at about 0700, (R1) had another unwitnessed fall in the hallway in front of his bedroom door and was found by Med Tech 2 (MT2) who assessed (R1) and reported on incident report that (R1) sustained an abrasion on his nose, forehead and left elbow. Interviews concluded that (R1) complained of discomfort and pain upon applying any pressure to his injuries to (MT2). Review of documentation concluded that (MT2’s) report and assessment was signed off by Health Service Director (HSD) Richard Mariona, Licensed Vocational Nurse on 1/24/2022 who was not present at the facility during any (R1’s) falls. There was no further document indicating follow up or additional assessment.
On 1/23/2022, at about 1415 hours, (R1) had a third unwitnessed fall and was found by Caregiver 1 (CG1), who assessed (R1) and reported to have no injuries and no discomfort and was instructed by (HSD) Richard Mariona via telephone to check on (R1) every 30 minutes or so for any change in condition.
On 1/24/2022, at about 0900 hours Caregiver 2 (CG2) was conducting routine rounds, and checked (R1) due to numerous reported falls. Interview with interviewee concluded that (R1) was unable to get up from bed and was complaining of pain on his right side. (R1’s) Family was contacted and asked if they wanted to come and pick up (R1) and transport him to the hospital. (R1’s) Family indicated “If you can’t move him out of bed how could I?” Facility called paramedics and (R1) was taken to Fountain Valley Hospital around 1100. (R1’s) Family arrived to the facility prior to (R1) being transported to Fountain Valley Hospital and took pictures of (R1’s) injuries. (R1) was examined by attending physician Dr. David Hamilton who diagnosed (R1) with fractured ribs from the fifth to the eight rib on the left side, weakness, head injury and a Pneumonia. (R1) was Admitted into Fountain Valley Hospital on 1/25/2022, and was discharged on 2/2/2022. Upon discharge, (R1) returned to reside with Family.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220131170149

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: PARK VIEW ESTATES	FACILITY NUMBER: 306005798
	VISIT DATE: 05/17/2022

NARRATIVE

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Continued...
Based on the preponderance of evidence gathered through multiple interviews and documents obtained; the allegation “Resident sustained multiple falls with consequential rib fractures” has been met; Therefore, the allegation listed above is deemed to be SUBSTANTIATED. The Facility Staff failed to accurately assess and provide timely medical treatment. The Facility failed to have appropriate supervision to ensure that (R1) was observed and adjusting well to his new residency resulting in three falls since date of admission of 1/21/2022. Interviews with interviewees concluded that facility is understaffed with little to no supervision on the weekend or evenings allowing for the caregivers and Medication Technicians to manage the facility. The facility failed to take preventative measures to decrease the risk of falls for (R1).
The facility is being cited per Title 22, Division 6 of the California Code of Regulations. Civil Penalty is being assessed at this time per Health & Safety Code 1569.49

An exit interview was conducted with Executive Director Sheila Fike and Richard Mariona, Health Service Director and a copy of this report, along with LIC9099-D, Appeal Rights, Civil Penalty Assessment-LIC 421 IM and the LIC 811, identifying confidential names was left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

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