306006030-11-7-2022-22-AS-AORZ-CL2V8Z-20221110151335

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006030
Report Date: 11/07/2022
Date Signed: 11/07/2022 12:38:15 PM

Unfounded

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
08/04/2022 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220804103041

FACILITY NAME:	MAJESTIC CARE VILLA INC.		FACILITY NUMBER:	306006030
ADMINISTRATOR:	FAJARDO, MIGUELITO		FACILITY TYPE:	740
ADDRESS:	25531 ALTHEA AVE		TELEPHONE:	(949) 290-3917
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	11/07/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Miguelito Fajardo, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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1/ Staff did not seek timely medical attention for resident.

2/ Resident was not regularly observed for changes in condition.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced inspection visit to deliver findings in the investigation of the allegations stated above. LPA was greeted and granted entry by Robert and Gaile Aquino, caregivers after explaining the purpose of the visit. Administrator was notified by phone and arrived later to assist with the visit.
It was alleged that Staff did not seek timely medical attention for resident and Resident was not regularly observed for changes in condition. During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation. Regarding the allegations that staff did not seek timely medical attention for resident and Resident was not regularly observed for changes in condition the following was concluded:
A review of the records and interviews concluded Resident 1 (R1) sustained a fall incident on 07/18/2020 which resulted in a hospitalization with a diagnosis of a closed hip fracture which was not surgically addressed due to an unfavorable risk assessment made by the health care providers at the time.
CONTINUED ON FORM LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

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-20220804103041

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: MAJESTIC CARE VILLA INC.	FACILITY NUMBER: 306006030
	VISIT DATE: 11/07/2022

NARRATIVE

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After the fall incident, medical records obtained confirm R1 was seen at least once every four weeks by their attending physician, as documented in visits dated 07/14/2020, 08/25/2020, 09/03/2020, 09/17/2020, 10/01/2020, 11/10/2020, 12/07/2020 and 12/29/2020. Monitoring of R1's skin condition is documented on each report and confirms the absence of sores or decubiti injuries until report dated 01/28/2021. Per medical records obtained, R1 was documented as having a newly occurred wound on the lower right posterior leg, followed up by a consultation on 02/03/2021 due to the wound worsening.

Following the medical assessment of the wound in late January/early February 2021, a referral for a wound care intervention was put into motion. Surveillance notes obtained from the wound care specialists note that caregivers reported that the wound occurred in January of 2021 and showed no progress since onset. The wound specialist notes further indicate that the wound incidence is “unavoidable due to Advanced Age; Decreased mental awareness; Fragile skin; Friction; Immobility or limited mobility; Medical Comorbidities; Vascular Factor.”

Resident was attended by home health regularly in addition to bi-weekly wound care continuously after that initial referral. Complete progress notes were obtained with detailed monitoring of the resident's condition throughout by a Home Health agency. Hospital records obtained dated 7/25/2022 show that R1 was hospitalized after the Home Health agency noted R1 had an altered level of consciousness. While at the hospital R1 was diagnosed with necrotizing fasciitis of the right vulva extending to the right inguinal region requiring surgery for debridement. At the time of incident R1 had a foley catheter in place which was being monitored by R1’s Home Health agency.

Although documentation obtained reveals R1 sustained a wound while in care, records obtained confirm facility staff ensured R1 received regular treatment for wound from Home Health Agency and sought medical treatment the same day Home Health nurses noted R1’s altered level of consciousness. Two of two staff interviewed confirmed R1 was receiving services from skilled medical professionals while at the facility. R1 was unable to be interviewed at the time of investigation due to being on a ventilator.

Based on the evidence gathered during the investigation, the allegations Staff did not seek timely medical attention for resident and Resident was not regularly observed for changes in condition are deemed to be unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis.
An exit interview was conducted with the facility representative and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

LIC9099 (FAS) - (06/04)

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