306005991-2-26-2024-22-AS-MSTC-D2X5ZN-20240229192414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005991
Report Date: 02/26/2024
Date Signed: 02/26/2024 02:06:05 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
12/28/2021 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20211228104511

FACILITY NAME:	GARDEN GROVE GUEST HOME LLC		FACILITY NUMBER:	306005991
ADMINISTRATOR:	YVETTE LEM		FACILITY TYPE:	740
ADDRESS:	12882 SHACKELFORD LANE		TELEPHONE:	(714) 638-9470
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	47	CENSUS: 41	DATE:	02/26/2024
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Ruben Ramirez		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Resident sustained unwitnessed fall at the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA met with Ruben Ramirez, Administrator and explained the nature of the visit.

Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which included interviews conducted, physical plant tour, and copy of pertinent documents obtained. It is alleged resident sustained unwitnessed fall at the facility. Review of records obtained resident (R1) is able to ambulate in the facility with assistance from a front wheel walker. Appraisal/needs and services plan indicate that R1 uses a front wheel walker to ambulate, plan is to use cane, objective is to remind resident to keep ambulation

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

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-20211228104511

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GARDEN GROVE GUEST HOME LLC	FACILITY NUMBER: 306005991
	VISIT DATE: 02/26/2024

NARRATIVE

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tools close at all times. Observe R1 for change of condition and assist R1 to meals if needed. Resident appraisal indicates R1 is non-ambulatory walker while ambulating. R1 has difficulty in hearing, but no hearing aids. R1’s speech is clear and language to make needs known. R1 does need assistance of areas for bathing, meal prep, laundry, and med management. R1 does toilet independently and able to do some of ADLS independently. R1 is alert and oriented with no cognitive defects and forgetfulness. Review of R1’s records has no indication that R1 required 1:1 assistance. R1 indicated that they were using the bathroom when they slipped and fell. Incident report submit to the Department indicated that when R1 was found by staff 911 was called immediately and R1 was assessed by paramedics and transferred to hospital for evaluation.

Based on the information gathered during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

This report was reviewed with Administrator and a copy was furnished to the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC9099 (FAS) - (06/04)

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