306006034-10-18-2022-22-AS-SSAS-CKUTZJ-20221104151026

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006034
Report Date: 10/18/2022
Date Signed: 10/18/2022 12:14:01 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
07/01/2022 and conducted by Evaluator Kathrina Chin

COMPLAINT CONTROL NUMBER: 22-AS-20220701142303

FACILITY NAME:	PHAMILY HOME ELDERLY CARE 2		FACILITY NUMBER:	306006034
ADMINISTRATOR:	PHAM, CHARLES		FACILITY TYPE:	740
ADDRESS:	16652 HUGGINS AVE		TELEPHONE:	(657) 724-9930
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 5	DATE:	10/18/2022
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Charles Pham		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident sustained bruising as a result of staff hitting resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Kathrina Chin conducted an unannounced visit to the facility to complete and deliver the findings of this complaint invesigation. LPA met with Charles Pham, Administrator.

The investigation into the allegation that resident sustained as a result of staff hitting resident revealed the following:

During the course of this investigation, LPA Chin contacted and talked with the responsible party, home health agency, Administrator, and facility staff and obtained statements. LPA reviewed the former resident's medical records. Upon reviewing R1's physician's report, R1 has been diagnosed with Dementia. R1 was also reported by a Home Health Agency staff and daughter who confirmed that R1 had Urinary Tract Infection(UTI) for several weeks prior to this incident. The responsible party of R1 stated that the Urinary Tract Infection(UTI) for multiple weeks and the infection along with the medication for the infection, was making R1 confused and unable to communicate effectively. (Continued on LIC 9099c)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

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-20220701142303

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: PHAMILY HOME ELDERLY CARE 2	FACILITY NUMBER: 306006034
	VISIT DATE: 10/18/2022

NARRATIVE

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On June 27, 2022, it was alleged that Resident 1 sustained a bruise as a result of a Staff 1 hitting the resident at around 5 AM. The Administrator Charles Pham called the Orange County Sheriff on the same day. LPA obtained the Orange County Sheriff's Report. The Orange County Sheriff Investigation Report indicated that Staff 1 denied hitting Resident 1 and S1 does not know how R1 sustained the injury on the face. S1 stated that he was assisting R1 with the changing of her clothes. R1 became agitated and aggressive. S1 reported that R1 scratched him on the face and that R1 is always hitting staff at the facility. Furthermore, Resident 1 was unable to answer any questions when asked by the Orange County Deputy Sheriff.

Staff 1 was the only staff working that morning on June 27, 2022 with six residents at the facility.
LPA attempted to speak to three residents, (R2, R3, R4) however, were unable to due to cognitive impairments. LPA Chin was unable to interview R1 as she moved out on June 29, 2022.

LPA made multiple phone calls in the attempt to interview Staff 1 but was unable to contact Staff 1.
Staff 2 was interviewed by telephone. Staff 3 was interviewed at the facility. LPA attempted to interview Staff 4 but was unable to contact him.

LPA Chin interviewed Charles Pham, Administrator and he believes that the redness on R1's face may be due to a chuck that has plastic polka dots on it. Mr. Pham believes that this chuck may have caused the redness on the resident's face. Mr. Pham stated that he initially thought that R1 had a rash on the right side of her face and did not have any bruising.

Based on the information gathered during the investigation and review of all documents obtained, the following allegation: Resident sustained bruising as a result of staff hitting resident was deemed Unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted, appeal rights explained and provided. A copy of this report was provided during the visit to Charles Pham, Administrator.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC9099 (FAS) - (06/04)

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