<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006452
Report Date: 06/19/2024
Date Signed: 06/19/2024 11:31:54 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
06/14/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240614132753
FACILITY NAME:ANAHEIM PALACEFACILITY NUMBER:
306006452
ADMINISTRATOR:CHON, CHRISTINE MFACILITY TYPE:
740
ADDRESS:525 W. LA PALMA AVETELEPHONE:
(626) 252-7287
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:199CENSUS: 181DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Eric ChangTIME COMPLETED:
11:55 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure medications are properly managed for residents in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. 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 residents as well as reviewed and obtained pertinent documentation such as medication administration record. Regarding the allegation that Staff does not ensure medications are properly managed for residents in care, the investigation revealed the following: Resident I (R1) is prescribed Oxycodone-Acetaminophen 5-325 (Percoset 5-325) three times daily. Facility documentation indicates reaching out to physician and pharmacy on three different occasions, 06/08, 06/10 and 06/11/2024 to obtain a refill for the medication. Resident missed three doses, evening dose on 06/13/2024 and morning/ afternoon dose on 06/14/2024. Medication review indicates a new pack was started on 06/14/2024. Facility staff indicate usual pharmacy changed operation by acquiring another pharmacy in June 2024 and did not notify facility timely. Based on interview and record review, CONTINUED ON LIC 9099C DATED 06/19/2024
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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 2
Control Number 22-AS-20240614132753
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: ANAHEIM PALACE
FACILITY NUMBER: 306006452
VISIT DATE: 06/19/2024
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
26
27
28
29
30
31
32
LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2