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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005940
Report Date: 09/21/2022
Date Signed: 09/21/2022 02:09:59 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
04/14/2022 and conducted by Evaluator Albert Marin
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220414121254
FACILITY NAME:ADULT CARE OC ACROPOLISFACILITY NUMBER:
306005940
ADMINISTRATOR:SZALONEK, FEFACILITY TYPE:
740
ADDRESS:24685 ACROPOLIS DRIVETELEPHONE:
(626) 864-9955
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Fe SzalonekTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility failed to provide necessary update on change of condition of a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Albert Marin and Celine De Perio made an unannounced visit to deliver the findings for the investigation completed for the complaint filed last April 14, 2022 against the facility. LPA met with Administrator (AD) Fe Szalonek, stated the purpose of this visit, and discussed the findings.

On allegation that the facility failed to provide necessary update on change of condition of a resident in care., the following are the findings. Resident 1 (R1) was placed under hospice care with primary diagnosis of Alzheimer’s Disease. Per file review of hospice and facility notes, R1 was observed to have behavior disturbances, frequent agitation towards staff and other residents, and non-compliance with medications. On April 5, 2022 R1 was highly agitated and refused to eat. Two care staff members held R1’s limbs in place to keep R1 steady as one staff member administered a routine oral liquid sedative (Trazodone) via syringe. Staff members observed R1 bit the syringe and heard a cracking sound after. Per interviews, it was around afternoon of April 6, 2022, when a staff member observed that R1’s front tooth was chipped off. Staff reported the observation to the responsible party a day after. (Continuation in Page 2)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 22-AS-20220414121254
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: ADULT CARE OC ACROPOLIS
FACILITY NUMBER: 306005940
VISIT DATE: 09/21/2022
NARRATIVE
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(Continuation from Page 1) On April 11, 2022, R1 fell down on the floor after an attempt to grab on something from the chair. R1 sustained a cut on the forehead. Staff member applied a cold compress. Facility missed to inform the responsible party and resident’s physician. On April 14, 2022 hospice agency assessed the wound and updated the care plan. Based on observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies observed, Citation was issued per Title 22 Division 6 of the California Code of Regulations.

LPAs Marin and De Perio conducted an exit interview with AD Szalonek LPA discussed the deficiencies citation, and appeal rights with AD. Copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20220414121254
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: ADULT CARE OC ACROPOLIS
FACILITY NUMBER: 306005940
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2022
Section Cited
CCR
87466
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Observation of the Resident. The... residents are regularly observed for changes .. and that appropriate assistance is provided when such observation reveals unmet needs. ...and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by:
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Facility will ensure that all new needs of the residents are recorded, and relay the changes to responsible party and physician. Threat reduced. Facility will provide training to staff regarding observation and reporting . Proof of training will be provided to CCLD in October 14, 2022. .
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Based on file review and interviews, facility observed changes in the resident, and missed to bring to the attention of the resident's physician and responsible person. R1 had a chipped off tooth, and had fall incident while in care. Responsible party was informed at least 2 days after the incident. This posed immediate threat on health and safety of resident in care.
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Copy of the cited regulation was provided to facility for full reference.
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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: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20220414121254
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: ADULT CARE OC ACROPOLIS
FACILITY NUMBER: 306005940
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2022
Section Cited
CCR
87468.1(a)(16)
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87468.1 Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services. This requirement was not met as evidenced by:
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Facility will provide training to staff members to ensure personal rights of the residents are observed at all times. Threat reduced. Facility will provide training on personal right and submit to CCLD on or before October 14, 2022.
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Based on file review, facility missed to observe the right of the resident to receive or reject medical care and other services. On 04/05/22, two staff members held R1's limbs to steady R1 as one staff member gave medication via syringe. This posed immediate threat against personal rights of the resident in care.
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Copy of the cited regulation was provided to facility for full reference.
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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: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4