306005827-12-27-2023-22-AS-SSAS-CYY2VT-20231228164428

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005827
Report Date: 12/27/2023
Date Signed: 12/27/2023 12:28:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/18/2021 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210518155603

FACILITY NAME:	COZY HOME SENIOR CARE		FACILITY NUMBER:	306005827
ADMINISTRATOR:	DUMALIANG, CZARINA S		FACILITY TYPE:	740
ADDRESS:	22272 TERNI		TELEPHONE:	(949) 583-9365
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS: 6	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	11:24 AM
MET WITH:	Paris Dumaliang, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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• Facility staff caused injury to resident.
• Facility staff handled resident in a rough manner.
• Facility staff did not seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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Licensing program analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrive at facility was greeted at the door by staff and granted entry. LPA spoke with Paris Dumaliang, Administrator and explained the purpose of the visit.

Findings are based upon this investigation which included file review, hospice records review, interviews conducted with staff and residents.

It is alleged that the facility staff caused injury to resident. Interviews, conducted with 2 of 2 facility residents indicate that there have never been signs of bad treatment from staff to residents. Residents indicate that they are treated good, and they get the care that is needed. Interview with residents reported there are no

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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-20210518155603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COZY HOME SENIOR CARE	FACILITY NUMBER: 306005827
	VISIT DATE: 12/27/2023

NARRATIVE

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concerns with staff at facility or any other residents and never observed any abusive behavior by the staff against any resident. Interview with witness revealed that they are not concerned with the care of the residents at the facility or of R1. They indicate that the care that R1 receives is good and that it brings them comfort to know that R1 is getting good care. They have no concerns that injuries are being cause by a staff member, they indicate that R1 has picking habit. R1 likes to pick and take off bandages when they have skin tears. Witness indicates that they don’t feel that the skin tears are done on purpose and knows that it happens because R1 has sensitive skin. Witness indicates that if they felt that R1 was not cared for appropriately they would have moved R1 out of the facility.

It is alleged that the facility staff handled residents in a rough manner. On May 14, 2021, assessment narrative – medical socials worker spoke with patients’ friend/power of attorney, that he reports to visiting patient regularly. He is pleased with the care that facility and hospice provide. He joked that it was suggested to him “you should get a room here." This comforting, knowing the patient feels well cared for. Describe patient's cognitive function: alert to self and immediate situation and can recall that I was there 10 minutes after I leave and come back, she is able to answer simple questions, she is forgetful and confused at times describe effects of anxiety on patient yells out with care being done, occasionally pushes away from caregiver refuses care. Indicate functional assessment staging fast score: ability to speak limited to approximately a half dozen different words or fewer, over an average day or in the course of an intensive interview.

It is alleged that facility staff did not seek medical attention in a timely manner. Interview with staff indicated that staff noticed a new skin tear and reported it to administrator. To which administrator indicated that a call was made to hospice to report new skin tear on or about May 16, 2021. The administrator received a call from the hospice on May 17, 2021, indicating that hospice was coming to see R1. Review of hospice records revealed the following: On May 10, 2021, interventions for safety concerns were in place and no concerns were identified. Records indicate other actual potential abuse/neglect risk factor: PT has a new skin tear in web of right hand between thumb and index, the staff reports from a cotton hand guard and the PT pulling it. This skin tear is in several months. May 20, 2021, document all autonomy concerns/ risk factors identified in focal assessment: no concerns/ risk factors identified this visit. Describe patient's cognitive function: patient is alert to self and current situation, easily confused and she answers questions inappropriately at times because patient cannot hear you and or you need to re state what you want. Indicate functional assessment

Continued on LIC9099-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20210518155603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COZY HOME SENIOR CARE	FACILITY NUMBER: 306005827
	VISIT DATE: 12/27/2023

NARRATIVE

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staging fast score: ability to speak limited to approximately a half dozen different words or fewer, over an average day or in the course of an intensive interview. On May 24, 2021, palm right skin tear inactivated onset date May 16, 2021, wound assessed inactivated wound completely.

Based on the information gathered during the investigation, interviews and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

This report was reviewed with Administrator and a copy was furnished to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

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