306005798-3-22-2022-22-AS-AJLO-CECTB4-20220512143428

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005798
Report Date: 03/22/2022
Date Signed: 03/22/2022 12:07:37 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
10/05/2021 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20211005172231

FACILITY NAME:	PARK VIEW ESTATES		FACILITY NUMBER:	306005798
ADMINISTRATOR:	HUNDLEY, SHANNON		FACILITY TYPE:	740
ADDRESS:	11360 WARNER AVE.		TELEPHONE:	(949) 333-3486
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	150	CENSUS: 71	DATE:	03/22/2022
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Heather Myers, Executive Director, Richard Mariona, Health Services Director		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident sustained injury due to a fall or improper care.

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 the course of 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 a fall or improper care, the following was concluded:
The investigation revealed that it was reported by the facility that Resident#1 (R1) suffered an unwitnessed fall on 9/24/2021. R1 was transported to Fountain Valley Hospital where R1 was diagnosed with a forehead hematoma and a black eye. As a result, R1’s responsible party placed a hidden camera in R1’s bedroom without notifying the facility.
On the morning of 9/30/2021, a video captured by the camera showed staff 1 (S1) in R1’s bedroom trying to assist with incontinence care and change R1’s bedding at approximately 5:10 AM. During the interaction with R1, S1 yanked on R1’s arms, legs and shoulders roughly in an effort to get R1 to stand up from the bed. CONTINUED ON NEXT PAGE...

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: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

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-20211005172231

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: 03/22/2022

NARRATIVE

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Per the video, S1 was observed pulling on R1’s leg at approximately 5:16 AM. Prior to pulling on R1’s leg, R1 can be seen in video being repositioned and moving freely without any evidence of pain or discomfort. Following the interaction, R1 began to continuously yell in pain. Despite R1’s yelling, S1 can be heard repeatedly instructing R1 to stand up and to stop yelling. As R1 grabbed onto bedding, S1 was observed yanking R1’s hands free in an effort to force her to stand up with the assistance of a walker which resulted in R1 sliding from the side of the bed onto the floor at 5:18 AM. S1 picked up R1 from by the waist and attempted to placed R1 on the bed again. When R1 reached out and placed a hand in front of them on the bed, S1 was observed forcibly shoving R1 from the back, face first onto the side of the bed with R1’s legs hanging over the edge of the bed. At 5:22 AM, S1 was observed grabbing R1 up by the ankles and lifting R1 off the floor and onto the bed. During this time R1’s full body weight can be observed resting on their head and neck. Throughout the incident R1 repeatedly yelled in pain and screamed for help. At no time during the incident did S1 call for assistance with R1. After attempting a second time to force R1 to stand, S1 was joined by R1’s responsible party at 5:25 AM who requested S1 to stop while they called for other caregivers to assist. At 5:34 AM S1 was joined by another caregiver who completed R1’s incontinence care with the help of R1’s responsible party. The facility staff did not call 9-1-1 or consult R1’s primary care physician.
R1 was later taken to Orange County Global Medical Center for evaluation by their responsible party on 10/02/2021 where R1 was diagnosed with a right inferior ramus fracture. Although the age of the fracture could not be determined, during R1’s hospitalization for an unwitnessed fall on 9/24/2021, a pelvic x-ray was completed and no mention of any pelvic injury was noted by the treating physician.
Per documents reviewed and interviews conducted, it was confirmed R1 was listed as a known fall risk. R1 is listed as having a diagnosis of Dementia and requires full assistance with ADLs. R1 was confirmed to be unable to communicate details of incidents that occurred on 9/24/2021 and 9/30/2021.
Interviews with interviewees concluded that although R1 was screaming “Help me, help me” while being assisted by S1. During the investigation, it was concluded that S1 was untruthful while providing answers and only told the truth after becoming emotional when shown photographs from the video captured.
S1 was hired by the facility via a temp agency to assist with staffing shortages. S1 was observed not to be associated to facility at the time of incident and no required paperwork, including staff training, was observed on file. S1’s contract with the facility has since been terminated.

CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20211005172231

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: 03/22/2022

NARRATIVE

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Based on the preponderance of evidence gathered through multiple interviews and documents obtained; the allegation “Resident sustained injury due to a fall or improper care” has been met; Therefore, the allegation listed above is deemed to be SUBSTANTIATED.
The facility is being cited per Title 22, Division 6 of the California Code of Regulations.
A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49
An exit interview was conducted with Administrator Heather Myers, and a copy of this report, along with LIC9099-D, Appeal Rights, 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: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20211005172231

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: 03/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/25/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 (a)(1) (Personal Rights of Residents in All Facilities) (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons.CONT BELOW...	1 2 3 4 5 6 7	Administrator will provide CCR 87468.1(a)(1) (Personal Rights of Residents in all facilities) training to all staff and submit proof of training by 3/25/2022.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on videos reviewed and interviews conducted, the licensee failed to ensure R1’s personal right were not violated as on 9/30/21, S1 was observed yanking on R1’s extremities and shoulder while assisting with ADLs. CONTINUED NEXT SECTION...	8 9 10 11 12 13 14	Despite R1’s repeated yelling in pain and calls for help, S1 continued to pull, shove and manipulate R1’s body in an effort to force R1 out of bed resulting in a diagnosed pelvic fracture. This poses an immediate health, safety and personal rights risk to persons 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 Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC9099 (FAS) - (06/04)

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