306005991-7-5-2024-22-AS-SSAS-D78NGB-20240716102649

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005991
Report Date: 07/05/2024
Date Signed: 07/05/2024 09:15:53 AM

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
02/22/2024 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240222150108

FACILITY NAME:	GARDEN GROVE GUEST HOME LLC		FACILITY NUMBER:	306005991
ADMINISTRATOR:	TISTOJ, RUTH		FACILITY TYPE:	740
ADDRESS:	12882 SHACKELFORD LANE		TELEPHONE:	(714) 638-9470
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	47	CENSUS: 41	DATE:	07/05/2024
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Daniel Lazareno-Medication Technician		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Resident sustained an unexplained fracture while in care of staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on February 22, 2024. LPA was greeted and granted entry into the facility and met with Medication Technician (MT) Daniel Lazareno. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that resident sustained an unexplained fracture while in care of staff. Resident 1 (R1) was admitted to the facility in October 20, 2022. Documents reviewed included the Physician Report (LIC602) dated March 01, 2023, for R1. Per Physician report R1’s diagnosis are osteoporosis and dementia. On November 27, 2023, R1 was admitted to Fountain Valley Hospital. The Hospital admitting diagnosis were abdominal pain, hyperkalemia, and dehydration. R1’s abdominal CT scan and chest x-ray demonstrated bilateral rib fractures including right lateral 7th and 8th ribs and left lateral 4th rib fracture.

CONTINUED ON LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

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-20240222150108

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: 07/05/2024

NARRATIVE

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During the course of the investigation LPA reviewed documents including the Unusual Incident/Injury Report (UIIR) dated November 29, 2023, for R1. Per UIIR on November 27, 2023, R1 complained of abdominal pain and being unable to have a bowel movement. 911 was called and transported resident to Fountain Valley Hospital. During the interviews with Fountain Valley Hospital admission Doctor, it was reported that falls contributed to fractures most of the time but that R1’s severe osteoporosis condition could cause the fractures. Per admission Doctor a variety of things could have cause those fractures, to name a few, severe coughing, during transportation via ambulance, etc. Per admission Doctor R1’s kidney stone and significant amount of stool within the rectal vault also contributed to the pain while at facility.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to insufficient evidence. Therefore, the allegation has been deemed to be UNSUBSTANTIATED.

LPA Ramirez conducted an exit interview with facility representative, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024

LIC9099 (FAS) - (06/04)

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