306006189-12-16-2022-22-AS-SHAD-CM6VY6-20221216155037

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006189
Report Date: 12/16/2022
Date Signed: 12/16/2022 03:50:45 PM

Document Has Been Signed on 12/16/2022 03:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	KAEGO'S RICHMAN GARDENS		FACILITY NUMBER:	306006189
ADMINISTRATOR:	HARVEY, LUPE		FACILITY TYPE:	740
ADDRESS:	317 N. RICHMAN GARDENS		TELEPHONE:	(213) 478-0460
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY:	26	CENSUS: 17	DATE:	12/16/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Rosalba Maldonado		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 11/14/22 regarding Resident #1 (R1) and Resident #2 (R2). LPA met with Staff #1 (S1) Rosalba Maldonado and discussed the purpose of the inspection. Administrator (AD) Lupe Harvey appeared via telephone. The incident report states that on 11/13/22, R1 attacked their roommate, R2, with a dresser drawer; R1 and R2 were immediately separated by facility staff; facility staff called 911 to request a 5150 evaluation; R2 was treated at a local hospital and returned a few hours later; the police took R1 to the county jail due to the nature of the incident; and R1’s family decided to remove R1 from the facility after the incident. During a previous inspection on 11/17/22, LPA conducted a health and safety check on R2 and observed that R2 had minor bruises but was otherwise in good health and was able to walk and LPA observed no health and safety issues. Long Term Care Ombudsman (LTCO) Jeannie Noh was present and interviewed R2 in Korean and stated that R2 stated that they are doing fine, but that R2 did not remember the incident. LPA interviewed staff who reiterated the information provided in the incident report. LPA requested and reviewed a copy of R1’s resident file. During today’s inspection, LPA interviewed AD who stated that prior to admission R1 lived with their family and was in the hospital after a fall and a urinary tract infection. LPA reviewed R1’s medical records dated 10/10/22 which state that R1 was admitted to the hospital on 09/24/22 for acute kidney injury and dementia with behavioral disturbance. AD stated that when the hospital was ready to discharge R1, R1’s family was unable to care for R1, so the hospital placed R1 on the Assisted Living Waiver (ALW). R1’s medical records dated 10/10/22 state that R1 has a history of dementia with psychotic/behavioral disorder and that R1’s family reported that R1 is aggressive and sometimes hits family members.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: KAEGO'S RICHMAN GARDENS	FACILITY NUMBER: 306006189
	VISIT DATE: 12/16/2022

NARRATIVE

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Per R1’s medical records dated 10/10/22, R1 was prescribed a psychotropic medication which improved R1’s agitation and a discharge plan was created for a long term memory care facility. LPA reviewed R1’s ALW assessment dated 09/27/22 which states that R1 is eligible for ALW at an assisted living facility and that the assessment was made by a registered nurse. Per AD, R1 was admitted to the facility on 10/10/22 and was sometimes agitated and aggressive, but not more so than other residents with dementia. The facility asked R1’s family to make a doctor’s appointment to reassess the medications to see if additional improvement could be achieved, but R1’s family did not understand the need and did not make the appointment. LPA interviewed S1 who corroborated AD’s statements. S1 also stated that R1 always took their medications, that R1’s level of agitation fluctuated, and that on 10/31/22 S1 sent R1’s doctor a description of R1’s agitation, a list of R1’s medications, and requested a reevaluation of R1’s medications, but neither S1 nor the facility heard back. At the time of the incident R1 had been at the facility for about 1 month and AD stated that R1’s behavior was unexpected based on their previous behavior.

Facility representative was advised that at this time further investigation may be required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

LIC809 (FAS) - (06/04)

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