306005960-5-20-2022-22-AS-AORZ-CF9NHG-20220610102839

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005960
Report Date: 05/20/2022
Date Signed: 05/20/2022 12:59:13 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
04/14/2022 and conducted by Evaluator Andrea Mendivil

COMPLAINT CONTROL NUMBER: 22-AS-20220414161926

FACILITY NAME:	WOODBRIDGE TERRACE		FACILITY NUMBER:	306005960
ADMINISTRATOR:	PRATT, STEPHEN		FACILITY TYPE:	740
ADDRESS:	1 WITHERSPOON		TELEPHONE:	(949) 654-8500
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY:	180	CENSUS: 115	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Terrie Sherrell		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Lack of care and supervision resulting in resident falling

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Terrie Sherrell and explained the reason for the visit.

During the course of the investigation, the Department interviewed staff, residents and witnesses as well as reviewed and obtained pertinent documentation such as physician report dated 04/04/2022, staff schedules, needs and service plan, health information dated 04/11/2022 and admission agreement. Regarding the allegation that facility lacked care and supervision which resulted in a resident’s fall, the investigation revealed the following:

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: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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-20220414161926

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: 05/20/2022

NARRATIVE

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Per reports, on 04/13/2022, Resident 1 (R1) was hospitalized after falling at Woodbridge Terrace. R1 was observed walking in the facility garden with their walker. Staff 1 (S1) was helping another resident when R1 tripped and fell back hitting their head against the floor. S1 called 911 and R1 was transferred to OC Global Hospital for further evaluation. S1 called R1’s daughter to notify of the fall and transfer to hospital.

R1 was discharged from OC Global Hospital on 04/17/2022 and returned to Woodbridge Terrace Memory Care. Upon R1 returning from the hospital, the facility reported they have implemented the following fall preventative measures for R1: fall mats, 2 person assists, and enhanced hourly status checks. Per interview with staff pain medication were added to R1 medications.

Interviews conducted with residents 3 out of 4 residents did not have concerns with lack of care and reported that staff treated them well. The 4th resident was unable to answer LPA questions due to not being alert to time and space. Based on health information dated 04/11/2022 R1 needs an escort to move about community. S1 was outside with R1 and another resident at the time of the fall. Based on an interview with R1 family, the family reported that R1 has had a history of falls in the past. Per physician wellness orders R1 is a fall risk and is not allowed lifting over 3 lbs.

Therefore based on the preponderance of evidence gathered, interviews conducted, records reviewed and observations made the allegation that facility lacked care and supervision resulting in a fall 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 and confidential names list was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

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