306006195-2-26-2025-22-AS-AORZ-DG3PA9-20250425110823

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006195
Report Date: 02/26/2025
Date Signed: 02/26/2025 05:31:20 PM

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
01/08/2025 and conducted by Evaluator Michael Tea

COMPLAINT CONTROL NUMBER: 22-AS-20250108143820

FACILITY NAME:	WESTMINSTER TERRACE		FACILITY NUMBER:	306006195
ADMINISTRATOR:	CRISTINA MILLER		FACILITY TYPE:	740
ADDRESS:	7571 WESTMINSTER BLVD		TELEPHONE:	(714) 891-6608
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY:	152	CENSUS: 108	DATE:	02/26/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Carmen Galicia		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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- Facility has a scabies infestation
- Facility staff is not administering resident's medication as prescribed
- Facility staff are not following the Infection Control Plan

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude the investigation and to deliver findings for the allegations mentioned above. LPA Tea was greeted and granted entry into the facility by Business Office Manager (BOM) Lakhena Lor and explained the reason for the visit. Executive Director (ED) Carmen Galicia arrived later to assist with the visit.

It was alleged that facility has a scabies infestation. During the investigation LPA interviewed residents and facility staff, checked, and reviewed resident files and charting. The investigation determined the following: It was reported a resident had scabies and that there was a possible scabies infestation at the facility. Per investigation and review of records, LPA Tea determined only one resident, Resident 1 (R1) had been diagnosed with scabies from hospital discharge paperwork and was prescribed medication to treat for scabies. From information obtained there were a total of five residents who allegedly had scabies, LPA spoke to the residents. Three out of five said they did not have, or recall having been infected by scabies. Resident 2 (R2) said that they thought they have scabies and was prescribed ointments and it

Continuation of Report on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

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-20250108143820

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: WESTMINSTER TERRACE	FACILITY NUMBER: 306006195
	VISIT DATE: 02/26/2025

NARRATIVE

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cleared up. R2 said the staff came to check their chest and determined it was a rash. R2 alert charting report does not show anything about scabies except for a roommate disturbance at night. Also, R2 shows no treatment for scabies in their file. One of the residents, Resident 3 (R3) who denied they had scabies showed on their alert charting report that they were treated for possible scabies. R3 said they felt itchy but there were no pest or mites in their room. LPA Tea reviewed their medical file and there is no paperwork indicating scabies. LPA spoke to the Health and Wellness Director (HWD), Brittainy Prieto, that since the 8 months she’s been here there has not been any residents diagnosed with scabies. Despite there is one resident who is diagnosed with scabies by the doctor there are no other indications showing there is an infestation.

It was alleged that facility is not administering resident’s medication as prescribed. The investigation determined the following: LPA checked and audited medications for R1 and Resident 4 (R4). All medications were accounted for and checked. LPA Tea checked the Medication Administration Record (MAR) which shows medication was given to residents as prescribed. Any discontinuation of medication and resident refusal was noted and documented correctly. HWD Prieto indicated there is no mismanaging of medications. Per interview with MedTech 1 (M1), stated they give medication as prescribed in the MAR and they follow and go by it. R1 stated that their medication was given as prescribed and had no problems. R1 also states they ask staff what medications they are taking most of the time.

It was alleged that facility staff are not following the Infection Control Plan. The investigation determined the following: It was indicated that facility was not following infection control plan. R1 indicated facility did not clean and sanitized their room when they had scabies. Per staff and management interviewed, right when R1 indicated they might have scabies they immediately followed protocol to treat the scabies. All the staff that were interviewed said they cleaned R1’s room following the orders of ED Galicia. They steam clean to kill the scabies mites on curtains and furniture. Staff also indicated that they washed R1’s laundry and bedding with hot water and high temperatures and kept secured in bags away from other residents’ laundry. Staff also placed a PPE supply bin for staff to use when cleaning or interacting with R1. On the initial unannounced visit of the complaint investigation on January 14, 2025, LPA Tea observed a PPE supply bin outside by the door of R1’s room. LPA also observed the room to be clean and sanitized at the time of initial visit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250108143820

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: WESTMINSTER TERRACE	FACILITY NUMBER: 306006195
	VISIT DATE: 02/26/2025

NARRATIVE

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Therefore, based on LPA Tea's observations and interviews conducted and records reviewed the allegations that facility staff has a scabies infestation, facility staff is not administering resident’s medication as prescribed, facility staff are not following the Infection Control Plan been determined to be unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies cited at this time and an exit interview was conducted with ED Carmen Galicia. A copy of the report and confidential names list was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025

LIC9099 (FAS) - (06/04)

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