306005960-9-29-2023-22-AS-AORZ-CWYLV3-20231026090448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005960
Report Date: 09/29/2023
Date Signed: 09/29/2023 02:48:11 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
09/22/2023 and conducted by Evaluator Andrea Mendivil

COMPLAINT CONTROL NUMBER: 22-AS-20230922134701

FACILITY NAME:	WOODBRIDGE TERRACE		FACILITY NUMBER:	306005960
ADMINISTRATOR:	MYRA LOZADA ARAGONES		FACILITY TYPE:	740
ADDRESS:	1 WITHERSPOON		TELEPHONE:	(949) 654-8500
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY:	180	CENSUS: 135	DATE:	09/29/2023
		UNANNOUNCED	TIME BEGAN:	10:31 AM
MET WITH:	Susie Mora - Assistant Executive Director		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility did not ensure residents receive their medications
Facility did not secure medication from residents in care

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Susie Mora, Assistant Executive Director/Memory Care Director and explained the reason for the visit.

The department received a complaint on 09/22/2023 and LPA Mendivil conducted the initial visit on 09/29/2023. During the visit LPA interviewed staff and residents and obtained copies of pertinent documents including: medication records and staff training records. Regarding the allegations facility did not ensure residents receive their medications and facility did not secure medication from residents in care, the investigation revealed the following:

It was alleged on 08/16/2023, 08/17/2023 and 08/20/2023 that 5 residents did not receive their medications. Based on interviews with Memory Care Director/Assitant Executive Director Susie Mora, the missed medication issue was brought to her attention on or around 09/21/2023. CONT on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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-20230922134701

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: WOODBRIDGE TERRACE	FACILITY NUMBER: 306005960
	VISIT DATE: 09/29/2023

NARRATIVE

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Susie stated they did an medication audit and were able to determine the medications were not missed but refused by residents and not properly documented by staff. Susie stated that staff has been retrained on medication refusal and how to properly document. Susie reported the physicians' of the residents were notified and no residents had adverse reactions.

During the visit LPA Mendivil observed a locked medication cart in Memory Care and a secured medication room. LPA observed a cabinet above med-tech desk which is not locked but contains paperwork and is secured by either a med-tech present or a locked door when staff is not in the room.

Based on interviews with 1 out of 1 staff indicate they received updated training on how to mark refusals in their system and denied residents missing medications due to their errors. Based on interviews with 3 out of 4 residents indicated they receive their medications without issue and are able to refuse medications if they want. The 4th resident stated that they did not receive medications.

Therefore, based on evidence through records reviewed and interviews the allegations Facility did not ensure residents receive their medications and Facility did not secure medication from residents in care are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint.
No deficiencies cited.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

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