306006313-7-8-2024-22-AS-MSTC-D7Q2TF-20240731174039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006313
Report Date: 07/08/2024
Date Signed: 07/08/2024 11:23:59 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
07/03/2024 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240703160942

FACILITY NAME:	FOUNTAIN OF YOUTH SENIOR LIVING		FACILITY NUMBER:	306006313
ADMINISTRATOR:	JERRAR, MOE A.		FACILITY TYPE:	740
ADDRESS:	525 N CAROUSEL PLACE		TELEPHONE:	(657) 208-3199
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY:	6	CENSUS: 6	DATE:	07/08/2024
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Brianna Bernal		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff are mean to the resident
Unqualified staff are performing blood glucose testing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to conduct the initial visit to begin the investigation into the allegations listed above. LPA met with Brianna Bernal, Assistant Administrator and explained the nature of the visit.

Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegations. Findings are based upon this investigation which included interviews conducted, tour of the physical plant of the facility and copies of pertinent documents obtained.

It is alleged facility staff are mean to residents. Interviews with four of six residents indicated that staff treat them well and are very courteous towards the residents. Resident indicated that they had no complaints

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion: 1

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

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-20240703160942

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: FOUNTAIN OF YOUTH SENIOR LIVING	FACILITY NUMBER: 306006313
	VISIT DATE: 07/08/2024

NARRATIVE

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of the care and treatment they received at the facility. Residents indicated that if anything they give the staff a hard time. Residents indicated that they do not have any complaints of the care or treatment they receive at the facility. Interview with 2 of 2 staff revealed that they have never witnessed any of the staff treating the resident mean and/or received any complaints from their peers about seeing staff treating the residents bad.

It is alleged that unqualified staff are performing blood glucose testing. Based on records review there is only one out of six resident that has a primary diagnosis of insulin dependent diabetes. Interview with resident R1 stated that R1 performs their own insulin injections and R1 indicated they don’t like that they must do injections, but they know they need it. R1 stated that they know that staff are not allowed to do the injections for them. Records review revealed that R1 has a Free style Libre 3 sensor on R1’s shoulder which gives an automatic glucose reading without requiring glucose testing to be done by a glucose meter. Interview with staff S1 indicated that the glucose reader is placed by R1’s daughter every two weeks. Interview with R1 revealed that R1 indicated that staff do not do any of the diabetes related task for R1 and R1 does their own injections. R1 indicated that staff hand R1 the insulin and stay in the room till R1 has completed the injection.

Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

LIC9099 (FAS) - (06/04)

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