306005899-2-29-2024-22-AS-AJLO-D3HSZ4-20240319141829

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005899
Report Date: 02/29/2024
Date Signed: 02/29/2024 01:41:15 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
08/31/2022 and conducted by Evaluator Claudia Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220831133413

FACILITY NAME:	IN R GREAT HANDS - MONTEVIDEO		FACILITY NUMBER:	306005899
ADMINISTRATOR:	IN, RIZA		FACILITY TYPE:	740
ADDRESS:	1261 MONTEVIDEO AVENUE		TELEPHONE:	(714) 646-9648
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 6	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	01:31 PM
MET WITH:	Tristan Raquipo		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident not assisted in timely manner

INVESTIGATION FINDINGS:

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An unannounced Complaint Investigation was conducted by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above for the purpose of delivering findings. LPA met with Staff Tristan Raquipo.

During the course of the investigation, LPA interviewed facility staff, Resident 1 (R1), and R1’s Responsible Party (RP), regarding Resident 1 (R1) not being assisted in a timely manner.

During interviews, three out of three staff denied not assisting resident in a timely manner. Per Staff 1 (S1), staff check on residents periodically, however checks are not on a set schedule, and are not documented. S1 stated R1 informed RP they sustained an unwitnessed after leaving the facility on 8/26/22 and stated there was no evidence or noise to alert that R1 fell. Per S1, R1 told RP that they did not inform anyone they had sustained a fall. (Cont. LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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-20220831133413

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: IN R GREAT HANDS - MONTEVIDEO	FACILITY NUMBER: 306005899
	VISIT DATE: 02/29/2024

NARRATIVE

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LPA interviewed R1’s RP, who stated that on 8/26/22, R1 was picked up from the facility by a family member to go to speech therapy and there was no indication R1 had fallen. Per RP, R1 also did not inform them of the fall. RP stated that later the same day, R1 informed another family member of the fall, and the family member then informed RP. RP stated R1 requested to go to the hospital, and they transported R1 to the hospital, where R1 was diagnosed with a hip fracture.

During their interview, R1 confirmed they had sustained an unwitnessed fall at the facility, while attempting to get to the restroom. R1 stated they became dizzy and fell but did not alert staff to the fall and staff were unaware they had fallen. Per R1, they did not alert staff or ask for help because they did not need staff assistance and were able to get back on their feet independently.

Due to conflicting information received during interviews conducted, LPA is unable to determine if resident was not assisted in a timely manner. Although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore at this time the above allegation is unsubstantiated.

An exit interview was conducted and copy of this report was provided at the end of the inspection.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

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