306006069-8-4-2022-22-AS-AJLO-CJUU3L-20221003151344

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006069
Report Date: 08/03/2022
Date Signed: 08/04/2022 07:58:39 AM

Substantiated

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
07/19/2022 and conducted by Evaluator Claudia Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220719085445

FACILITY NAME:	IVY PARK AT BRADFORD		FACILITY NUMBER:	306006069
ADMINISTRATOR:	BOOTH, KEVIN		FACILITY TYPE:	740
ADDRESS:	1180 N BRADFORD AVE		TELEPHONE:	(714) 996-9292
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	136	CENSUS: 87	DATE:	08/03/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Executive Director Rose Calabrese		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained injury while being transferred from Hoyer Lift to wheelchair.

Staff members did not follow resident's medical orders.

INVESTIGATION FINDINGS:

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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Executive Director (ED) Rose Calabrese and discussed the purpose of the visit.

Complaint alleges resident sustained injury while being transferred from Hoyer Lift to wheelchair and staff members did not follow resident's medical orders.

Interviews were conducted with Memory Care Director (MCD) Grace Cruz, Health Services Director (HSD) Neha Patel, Executive Director (ED) Rose Calabrese and care staff. During interviews MCD stated they did not know if care staff was aware of Resident 1’s (R1’s) new medical orders. HSD also stated they did not know if care staff was aware of R1’s new medical orders. ED stated they did not think care staff was aware of the new doctor's order "in the moment." Care staff stated they were not aware R1’s doctor’s order for Hoyer lift had changed from a two-person assist to a three-person assist. (Cont. LIC9099-C)

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

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-20220719085445

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: IVY PARK AT BRADFORD	FACILITY NUMBER: 306006069
	VISIT DATE: 08/03/2022

NARRATIVE

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Interdisciplinary Plan of Care Revision dated 7/15/22 indicates doctor’s order was for a three-person assist. R1 sustained injury on 7/17/22 while being transferred from Hoyer lift to wheelchair by two-person assist. Staff members did not follow R1’s medical orders for a three-person assist. The preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated by the California Code of Regulations, Title 22, Health and Safety Code section 1569.2(c). Per disclosures made during interviews and records obtained by LPA it was determined staff members did not follow resident's medical orders dated 7/15/22 and R1 sustained an injury while being transferred from Hoyer Lift to wheelchair.

An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220719085445

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: IVY PARK AT BRADFORD	FACILITY NUMBER: 306006069
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/04/2022 Section Cited HSC 1569.2(c)	1 2 3 4 5 6 7	1569.2 Health and Safety Code section (c)... the facility assumes responsibility for… assistance with activities of daily living without which the resident’s physical health… safety, or welfare would be endangered. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Executive Director (ED) Rose Calabrese stated a sign has been placed in Resident 1's (R1's) bedroom, which LPA observed. The sign displayed was observed to have instructions on how many people are required to assist with Hoyer lift and step by step instructions on how to complete transfer.
	8 9 10 11 12 13 14	Based on interviews conducted, the facility did not assume responsibility for resident’s physical health; hence, endangering resident’s welfare which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	An in-service will also be held on 8/10/22 with Vitas hospice company and all facility care staff on how to properly complete Hoyer lift transfer. ED will provide LPA with in-service training log once training is completed.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC9099 (FAS) - (06/04)

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