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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001093
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:56:09 PM

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
04/30/2023 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230430182419
FACILITY NAME:ROCHELLE MANORFACILITY NUMBER:
306001093
ADMINISTRATOR:ALFREDO RINGORFACILITY TYPE:
740
ADDRESS:12841 ADELLE STTELEPHONE:
(714) 537-3188
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:20CENSUS: 13DATE:
05/15/2023
ANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Foster RingorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff did not prevent resident's pressure injuries from reoccurring while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Caregiver Cindy Santos and explained the reason for the visit. Administrator Foster Ringor was present as well.
During the course of the investigation, LPA toured the facility, interviewed staff and resident as well as reviewed and obtained pertinent documentation such as physician report and facility notes. Regarding the allegation that facility staff did not prevent resident's pressure injuries from reoccurring while in care, the investigation revealed the following: Resident 1 (R1) is non-ambulatory and diagnosed with Severe Cerebral Palsy. Facility documentation shows resident has been dealing with chronic pressure injuries since at least 2019. R1's Individual Program Plan (IPP) dated 10/28/2022 outlines resident's history of wounds and the importance of managing the wounds. Since 12/16/2022, R1 was seen at urgent care or by physician five times (12/16/2022, 01/20/2023, 02/17/2023, 03/14/2023 and 04/28/2023) for dermatitis/ pressure injuries and prescribed topical creams. No other interventions were prescribed and staff requested side support cushion for resident. Administrator states requesting home health for resident CONTINUED ON LIC 9099C DATED 05/15/2023
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
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-20230430182419
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: ROCHELLE MANOR
FACILITY NUMBER: 306001093
VISIT DATE: 05/15/2023
NARRATIVE
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but was denied due to the low staging of wounds. Administrator states wounds are stage 1 but there is no staging in any medical paperwork. Four out of four staff indicate turning resident and applying topical creams. Facility paperwork indicates creams were being applied to resident. LPA observed pillow configuration for R1's wheelchair. Based on multiple interviews conducted and documents reviewed, there is not enough evidence or corroborating information to support 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 with Administrator and a copy of this report was emailed to Administrator.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2