306005835-2-14-2023-22-AS-LADS-CP4TXK-20230216140713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005835
Report Date: 02/06/2023
Date Signed: 02/14/2023 12:22:21 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
10/26/2022 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221026170408

FACILITY NAME:	KIRKWOOD ORANGE		FACILITY NUMBER:	306005835
ADMINISTRATOR:	ZEHRA, SYED		FACILITY TYPE:	740
ADDRESS:	1525 E TAFT AVENUE		TELEPHONE:	(714) 282-1409
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	66	CENSUS: 56	DATE:	02/06/2023
		UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Executive Director-Sarah John		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained a fracture while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Facility Administrator, Sarah John and stated the purpose of this visit which was to deliver the final findings for the complaint received on 10/26/22 against this facility.

This agency has investigated the complaint alleging that resident sustained a fracture while in care. LPA De Perio conducted file reviews and interviews with staff and residents. During the investigation, LPA was informed that the facility conducted an internal investigation about this incident, and formulated 1 out of the 2 conclusions:

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

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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Control Number 22-AS-20221026170408

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: KIRKWOOD ORANGE	FACILITY NUMBER: 306005835
	VISIT DATE: 02/06/2023

NARRATIVE

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1) Resident’s legs are pointed inwards, and the NOC shift caregiver who was assigned to the resident “was not paying attention” to the direction of the resident’s legs and moved it the wrong way when it was time to change the resident’s diaper.

2) The resident moved her legs the wrong way on her own and her leg may have gotten leg stuck between the wall and bed. The NOC shift caregiver who was assigned to resident may have observed the injury upon changing resident’s diaper, however, failed to report the incident and observation made to a supervisor.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

For today’s visit, deficiencies were issued per Title 22, California Code of Regulations.

LPA De Perio conducted an exit interview with Facility Administrator, Sarah John, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20221026170408

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: KIRKWOOD ORANGE	FACILITY NUMBER: 306005835
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/06/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).	1 2 3 4 5 6 7	As plan of correction (POC), facility administrator will provide training to staff regarding the indicated regulation and will obtain a signed and dated document of staff present during training. Facility will provide POC to assigned LPA on or by 2/20/23.
	8 9 10 11 12 13 14	This standard is not met as evidenced by: Based on observation, record reviews and interviews, facility did not comply with the section cited above. Facility administrator confirmed with LPA that resident did sustain a fracture while in care and that staff on duty failed to report it.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC9099 (FAS) - (06/04)

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