306006247-4-10-2024-22-AS-AORZ-D6YT2F-20240708142038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006247
Report Date: 04/10/2024
Date Signed: 04/10/2024 09:10:03 AM

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
03/28/2024 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20240328103849

FACILITY NAME:	FAMILY CHOICE SENIOR LIVING		FACILITY NUMBER:	306006247
ADMINISTRATOR:	JUNGE, PAMELA		FACILITY TYPE:	740
ADDRESS:	3105 W. ORANGE AVENUE		TELEPHONE:	(714) 229-0069
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	30	CENSUS: 17	DATE:	04/10/2024
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Pamela Junge		TIME COMPLETED:	09:00 AM

ALLEGATION(S):

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Facility abandoned resident at the hospital
Facility failed to report residents change in condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and witnesses. LPA reviewed and obtained pertinent documentation such as hospital progress notes dated 04/02/2024 and 04/05/2024. Regarding the allegations that facility abandoned resident at the hospital and facility failed to report residents change in condition, the investigation revealed the following: Resident 1 (R1) was admitted to Kaiser on 03/16/2024 for evaluation of ostomy, skin wounds and urinary tract infection. Resident has a history of antibiotic resistant infection as well as fistula in the abdomen. Resident was being treated by home health at the facility for the fistula prior to hospitalization. Per Kaiser Case Manager RN, resident had no active infection and was ready for discharge on 03/19/2024. Interview with Case Manager indicated Facility Administrator did not want to accept the resident back into the facility due to the history of infection and was unresponsive to calls. CONTINUED ON LIC 9099 C DATED 04/10/2024

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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-20240328103849

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: FAMILY CHOICE SENIOR LIVING	FACILITY NUMBER: 306006247
	VISIT DATE: 04/10/2024

NARRATIVE

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Facility Administrator did not assess the resident at the hospital until 04/06/2024 after multiple conversations with Licensing. Updated physician report dated 04/05/2024 indicates resident is now bedridden and outside licensing regulations as facility does not have a bedridden fire clearance. Administrator provided incident reports dated 03/13/2024 and 03/16/2024 regarding hospitalization of R1. Administrator indicates faxing the reports to the department but does not have a fax receipt. Department regulations require facilities to report incidents to responsible parties, licensing, and physician but the requirement does not apply to outside agencies. Based on interviews conducted and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC9099 (FAS) - (06/04)

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