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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006314
Report Date: 09/12/2025
Date Signed: 09/12/2025 09:39:25 AM

Substantiated


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
05/27/2025 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250527154814
FACILITY NAME:HILLS OF BROWNING, THEFACILITY NUMBER:
306006314
ADMINISTRATOR:MAR JASON DASCOFACILITY TYPE:
740
ADDRESS:12911 BROWNING AVENUETELEPHONE:
(714) 430-7672
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:0CENSUS: 0DATE:
09/12/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Licensee Allen MedinaTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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Resident developed pressure injury due to lack of care and supervision
Facility did not notify family regarding pressure injury
INVESTIGATION FINDINGS:
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On September 12, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Licensee Allen Medina and explained the reason for the visit. During the course of the investigation, LPA inspected the facility, interviewed staff and residents, obtained and reviewed resident records.

The investigation revealed the following: It was alleged that a resident developed a pressure injury due to lack of care and supervision. Resident #1 (R1) was admitted to the facility on April 25, 2025. R1 was also admitted under hospice care on April 25, 2025. R1 moved out of the facility on May 29, 2025, as R1 was admitted to the hospital and did not return to the facility once discharged. Per R1’s Physician Report dated April 28, 2025, R1 has a diagnosis of Alzheimer's disease and Dementia. R1 was on a mechanical soft diet; requires medical supervision for bowel and bladder impairment; motor impairment/paralysis; is non-ambulatory and requires assistance with all Activities of Daily Living (ADLs). CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 22-AS-20250527154814
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: HILLS OF BROWNING, THE
FACILITY NUMBER: 306006314
VISIT DATE: 09/12/2025
NARRATIVE
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LPA reviewed the hospice care reports for R1 dated between April 25, 2025, to May 28, 2025, which stated that on April 25, 2025, R1 has a diagnosis of senile degeneration of the brain, dysphagia, unspecified dementia, chondromalacia patellae in left and right knee, hypothyroidism, heart disease, chronic pain syndrome, essential hypertension, hyperlipemia, gastroesophageal reflux disease without esophagitis, chronic kidney disease, weakness, depression, and generalized anxiety disorder. A skin assessment was done on R1 upon admission on April 25, 2025, in which R1’s skin was normal and intact. R1 was a high risk for pressure ulcers. Per the hospice report dated April 26, 2025, R1 continues to be at high risk for pressure injuries due to immobility and chronic pain. Staff were advised to reposition R1 every two hours to maintain skin integrity, and that staff verbalized understanding of the instructions and to participate actively in R1’s plan of care. Per hospice report dated May 9, 2025, R1 had developed stage 2 pressure sore on her coccyx. The hospice reports further details that wound care treatment was done during the visit and that wound care services for R1 were requested. On May 12, 2025, wound care treatment was done on R1 and staff were advised to continue turning R1 every two hours for wound care prevention and worsening of the wound. On May 23, 2025, R1 continued to develop a stage 2 pressure sore on her coccyx and staff were reinforced to reposition R1 every two to three hours on her sides to off-load pressure on her coccyx. Staff verbalized understanding of the instructions. Hospice care report dated May 28, 2025, a Foley catheter was inserted in R1 for wound management. LPA reviewed the wound care specialist reports for R1 dated between May 12, 2025, and May 27, 2025, which stated that R1 has a pressure induced deep tissue damage of left heel and an unstageable pressure ulcer of sacral region.

LPA conducted interviews with four (4) witnesses from R1’s hospice agency. Witness #1 (W1), who admitted R1 was under hospice agency on April 25 and April 26, 2025. W1 confirmed that upon R1 admission, a skin assessment was done on R1 in which R1’s skin was normal, did not have any redness or open wounds. W1 confirmed that R1 was a high risk for pressure ulcers due to R1’s immobility and diagnoses. Four out of four witnesses interviewed confirmed that during hospice visits, orders were given to facility staff to reposition R1 every 2-3 hours to maintain skin integrity and facility staff on duty verbalized to hospice nurse's that they understood the instructions to reposition R1 every 2-3 hours. LPA interviewed five facility staff who were involved in R1’s care between April 25 and May 29, 2025. Five out of five staff confirmed that R1 was not being repositioned every 2-3 hours since April 25, 2025. LPA reviewed the facility’s R1 turning chart records that shows the facility only documented R1 being repositioned on May 28 and May 29, 2025.

CONTINUED ON LIC9099-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20250527154814
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: HILLS OF BROWNING, THE
FACILITY NUMBER: 306006314
VISIT DATE: 09/12/2025
NARRATIVE
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Facility staff did not consistently reposition R1 every 2-3 hours per hospice care instructions which resulted in R1 being admitted to the hospital on May 29, 2025, due to a wound infection described as a large decubitus ulcer on the back, which was very foul smelling, with yellow-colored discharge draining from it, involving skin subcutaneous tissues, at least to muscle. R1 was discharged from the hospital on June 7, 2025, and was transferred to a skilled nursing facility for a higher level of care for wound care treatment.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, resident developed pressure injury due to lack of care and supervision. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division.

The investigation revealed the following: It was alleged that the facility did not notify the family regarding pressure injury. LPA conducted an interview with R1’s Power of Attorney (POA) who confirmed that the facility did not notify him of R1 developing a pressure injury. The POA stated that he learned about R1’s pressure injury from a wound care specialist who was requesting to treat R1 for her wound. During staff interviews, LPA received an admission from the facility Administrator (AD). The AD confirmed that R1’s family was not being updated regarding R1’s change of condition and that the AD regretted not keeping them updated.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, facility did not notify the family regarding pressure injury. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Licensee Allen Medina. A copy of the report and Appeal Rights were provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20250527154814
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: HILLS OF BROWNING, THE
FACILITY NUMBER: 306006314
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not evidenced by:
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The Licensee stated that they will review the regulation cited. The Licensee agreed to provide a written statement of understanding of the regulation to LPA via email or fax by POC date.
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Based on documents reviewed and interviews conducted, the Licensee did not ensure staff were following R1’s hospice care plan which caused R1 to develop pressure-induced deep tissue injury on the left heel and an unstageable pressure ulcer on the coccyx. This poses an immediate health and safety risk to persons in care. Civil Penalty Assessed.
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Type A
09/15/2025
Section Cited
CCR
87463(f)
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87463 Reappraisals: (f) The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation...
This requirement is not evidenced by:
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The Licensee stated that they will review the regulation cited. The Licensee agreed to provide a written statement of understanding of the regulation to LPA via email or fax by POC date.
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Based on interviews conducted, the Licensee did not ensure that R1’s family was notified of R1’s change of condition as a result of the pressure-induced deep tissue injury on the left heel and an unstageable pressure ulcer on the coccyx of R1. This poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4