306006146-4-26-2024-22-AS-SSAS-D4U2JR-20240430172645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006146
Report Date: 04/26/2024
Date Signed: 04/26/2024 11:44:28 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
01/02/2024 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240102092921

FACILITY NAME:	SEA CLIFF ASSISTED LIVING		FACILITY NUMBER:	306006146
ADMINISTRATOR:	CLARK, TAYLOR		FACILITY TYPE:	740
ADDRESS:	18851 FLORIDA STREET		TELEPHONE:	(714) 847-3999
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92648
CAPACITY:	84	CENSUS: 51	DATE:	04/26/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator-Taylor Clark		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained unexplained fracture while in care due to neglect

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 January 02, 2024. LPA was greeted and granted entry into the facility and met with Administrator (AD) Taylor Clark. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that Resident sustained unexplained fracture while in care due to neglect. Resident 1 (R1) was admitted to the facility on October 04, 2022. Documents reviewed included the Physician Report (LIC602) dated August 16, 2023 for R1. Per Physician report R1’s diagnoses are Status post joint replacement surgery, Alzheimer’s, Arthritis, Dementia and is Non-ambulatory. On June 13, 2023, R1 sustained a displaced femoral neck fracture while out of the facility with family. R1 went to a Skill Nursing Facility from June 2023 to August 2023. The Unusual Incident/Injury Report (UIIR) on December 26, 2023, reports R1 had an unwitnessed fall, hit their head and fracture their left femoral. Per the UIIR on December 31, 2023, R1 had an unwitnessed fall and was bleeding from their head.
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: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

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-20240102092921

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: SEA CLIFF ASSISTED LIVING	FACILITY NUMBER: 306006146
	VISIT DATE: 04/26/2024

NARRATIVE

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On December 26, 2023, R1 was hospitalized at Hoag Memorial Hospital after an unwitnessed fall and was admitted for left shaft fracture. During the course of the interviews AD stated that on December 26, 2023, R1 fell when they attempted to transfer into their wheelchair and reported that the wheelchair wheels were not locked. Per AD, R1 had surgery on December 27, 2023, and was discharged into the facility on December 28, 2023. On December 31, 2023, R1 was hospitalized at the University of California (UCI) Health after a second unwitnessed fall and was admitted for Traumatic subdural hemorrhage with loss of consciousness. AD reported that on December 31, 2023, R1 had an unwitnessed fall while trying to use the restroom. On January 02, 2024, R1 was discharged from the hospital with a diagnosis of subdural hematoma. Documents reviewed included the UCI Health Discharge Summary dated January 02, 2024, for R1. Per Discharge Summary given the absence of significant mass effect, R1 will not require operative neurosurgical intervention and R1’s staples from the fall need to be removed on January 08, 2024. Documents reviewed included the Hoag Home Health Records dated January 04, 2024, for R1 confirmed receipt of the staple removal order.

Based on the investigation, there was no evidence to corroborate the allegation of neglect by staff resulting in R1’s falls and injuries that occurred on December 26 and December 31, 2023. Per physician report the R1 was not a fall risk and 911 was initiated timely and R1 was transported to Hoag Memorial Hospital and UCI Health respectively.

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 AD Clark, 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: 04/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024

LIC9099 (FAS) - (06/04)

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