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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006019
Report Date: 03/11/2024
Date Signed: 03/11/2024 04:25:49 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
12/12/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231212161617
FACILITY NAME:CRESCENT LANDING AT GARDEN GROVE MEMORY CAREFACILITY NUMBER:
306006019
ADMINISTRATOR:LOPEZ, DARLENEFACILITY TYPE:
740
ADDRESS:11848 VALLEY VIEW STREETTELEPHONE:
(419) 247-2800
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:72CENSUS: 45DATE:
03/11/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Darlene Lopez, Executive DirectorTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Lack of supervision resulting in resident sustaining multiple falls

Lack of supervision of resident resulting in a hip fracture
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the two allegations listed above. LPA was greeted and granted entry by facility administrator Darlene Lopez after stating the reason for the visit and listing the allegations.

An initial complaint investigation visit was conducted on December 19, 2023. LPA reviewed resident records for resident R1 including the physician report established upon admission in October 2020, the updated medical assessment dated March 23, 2023 as well as documents related to medication prescription, hospice admission after August 2023 and an admission at Los Alamitos Medical Center from December 8, 2023 until December 12, 2023 during which R1 received surgery for a hip fracture. Additional records were requested from Los Alamitos Medical Center via subpoena on January 11, 2024.

CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
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 2
Control Number 22-AS-20231212161617
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: CRESCENT LANDING AT GARDEN GROVE MEMORY CARE
FACILITY NUMBER: 306006019
VISIT DATE: 03/11/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099

Resident R1 was admitted to Los Alamitos Medical Center for a fall sustained on December 8, 2023 for which paramedics were called. R1 sustained a hip fracture and was operated to treat the fracture, then discharged back to the community on December 12, 2023. R1 eventually passed away on December 14, 2023. The death report submitted by the facility to the Department states the cause of death as "Multip[le] System[ic] Failure due to symptoms related to end stage Alzheimer's dementia". Records reviewed showed that R1 had been identified by facility staff to constitute an increased fall risk as early as October 10, 2020 and had notified the family accordingly upon admission. Evidence of an adjustment in medication show that R1's Xanax dosage had been increased by the hospice physician on December 1, 2023 stating "frequency increased due to increased restlessness. Ordered by Dr. Dayrit and consent to by [daughter]". Orders from the same date indicate that facility staff was authorized to use "tab alarm in bed and wheelchair to alert staff of unassisted transfers" and "may keep bed low with floor mattress", indicating both an awareness of the fall risk and measures taken to address it. LPA was additionally able to review hospice admission notes dated August 9, 2023 stating that R1 was "Declining, not eating with weight loss, episodes of [shortness of breath] and low heart rate". Visit notes from the attending hospice nurse dated November 30, 2023 also mention a fall incident with no injury and indicates that the prescription adjustment had been requested directly within hospice staff with no mention of facility staff. Hospice notes following the readmission on December 12, 2023 confirm that the death was pronounced by the hospice physician and details extensive comfort measures taken during that time.

Regarding the allegations that Lack of supervision resulting in resident sustaining multiple falls and Lack of supervision of resident resulting in a hip fracture, the following has been concluded: Based on records reviewed, it was determined that both the fall risk at baseline and the elevation of R1's fall risk due to R1's declining condition had been assessed and were being addressed through vigilance measures by facility staff with the assistance of the attending hospice professionals. Therefore the allegations are found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2