374601685-7-26-2024-18-AS-JDHS-D7PP72-20240731110312

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601685
Report Date: 07/26/2024
Date Signed: 07/26/2024 02:58:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2022 and conducted by Evaluator Jacqueline Shaw Ross

COMPLAINT CONTROL NUMBER: 18-AS-20220426091412

FACILITY NAME:	REGENCY FALLBROOK		FACILITY NUMBER:	374601685
ADMINISTRATOR:	KARI MORENO		FACILITY TYPE:	740
ADDRESS:	609 E.ELDER STREET		TELEPHONE:	(760) 728-8504
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY:	75	CENSUS: 61	DATE:	07/26/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Kari Moreno, Executive Director		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff caused bruises to resident while in care.
Staff failed to properly supervise staff with residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an unannounced visit to deliver findings for the investigation of the complaint with the above allegation(s). LPA Shaw Ross and met with Kari Moreno, Executive Director and advised them of the purpose of today's visit. Below is a summary of the findings of the investigation:

Regarding allegation "Staff inappropriately handled resident while in care.": Interviews were conducted, as well as records and photos were additionally reviewed regarding the allegation. In the morning of April 21, resident #1 (R1) was being assisted by Staff #1 (S1) for a bowel movement (BM) where R1 soiled self and areas around restroom. S1 attempted to assist R1 with cleaning and dressing, however, R1 became agitated and pushed S1 away (refusing assistance). When R1 calmed down, S1 was able to assist R1 with cleaning and dressing. Afterwards, S1 immediately reported the incident to a co-worker and facility administrator. R1 was evaluated by on-site Licensed Vocational Nurse (LVN) and no transportation was required. Over the following two days, bruising began to show and increase. Facility staff photographed the bruising, notified family members and reported to incident as required.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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 18-AS-20220426091412

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: REGENCY FALLBROOK	FACILITY NUMBER: 374601685
	VISIT DATE: 07/26/2024

NARRATIVE

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Based on the above information, there is no evidence to support staff physically abused or was negligent in the care or treatment of R1. The investigation did not reveal that facility staff contributed to the bruises seen on both forearms and subsequent injuries sustained by R1. It is believed that R1 might have hit arms and hands on nearby restroom rails and counter. Therefore, the allegation that "Staff inappropriately handled resident while in care" is deemed to be UNSUBSTANTIATED

Regarding allegation "Staff failed to properly supervise staff with residents in care." Interviews were conducted, as well as records and photos were additionally reviewed regarding the allegation. In the morning of April 21, resident #1 (R1) was being assisted by Staff #1 (S1) for a bowel movement (BM) where R1 soiled self and areas around restroom. S1 attempted to assist R1 with cleaning and dressing, however, R1 became agitated and pushed S1 away (refusing assistance). When R1 calmed down, S1 was able to assist R1 with cleaning and dressing. Afterward, S1 immediately reported the incident to a co-worker and facility administrator. R1 was evaluated by on-site Licensed Vocational Nurse (LVN) and no transportation was required.

Over the following two days, bruising began to show and increase. Facility staff photographed the bruising, notified family members and reported to incident as required. Based on the above information, there is no evidence to support staff failed to provide assistance as needed or was negligent in the care or treatment of R1. The investigation did not reveal that facility staff contributed to the bruises seen on both forearms and subsequent injuries sustained by R1. Therefore, the allegation that "Staff failed to properly supervise staff with residents in care" is deemed to be UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Kari Moreno, Executive Director, and a copy of this report was provided.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC9099 (FAS) - (06/04)

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