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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002065
Report Date: 02/15/2023
Date Signed: 02/15/2023 01:59:41 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
07/28/2021 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210728122029
FACILITY NAME:LAS PALMAS HOME CAREFACILITY NUMBER:
306002065
ADMINISTRATOR:MARTHA SERNAFACILITY TYPE:
740
ADDRESS:116 W. LAS PALMAS DR.TELEPHONE:
(714) 773-0055
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:6CENSUS: 6DATE:
02/15/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Veronica SernaTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff are not conducting medication management
Facility staff are not practicing Covid Protocols
Facility is in disrepair
Staff showering in resident bathroom
No covered trash cans for solid waste
INVESTIGATION FINDINGS:
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Licensing Program Analyst Michelle Reed arrived at the facility to complete this complaint investigation. deliver the findings of this complaint investigation. Upon arrival, LPA met with Veronica and Lourdes Serna. Administrator Martha Serna was off. The investigation consisted of a review of medications for Resident #1(R1) and interviews with Administrator, staff and witnesses as well as R1. The following was determined:

R1 was admitted into the facility 7/12/21. R1 needed assistance with her medications and ADL's. She was also receiving hospice care. On 7/30/21, at the time of visit, staff were wearing masks and took LPA’s temperature upon arrival. There was also a screening table present with a sign in sheet before entering the facility. R1’s medications were observed in a locked cupboard on 7/30/21. According to staff R1 would often refuse her medications. R1's physician's report also documented her noncompliance with medications. LPA also toured the facility at the time of visit and no disrepair was noted at that time. Trash cans were covered for solid waste. According to staff interviewed solid waste is immediately taken outside. Staff and R1 were interviewed. Staff do not shower in R1’s restroom. There is a staff restroom with a shower just off the dining room.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
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-20210728122029
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: LAS PALMAS HOME CARE
FACILITY NUMBER: 306002065
VISIT DATE: 02/15/2023
NARRATIVE
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Based upon interviews and LPA’s observations, these allegations are unsubstantiated, meaning that although the allegations may have happened or were valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of this report was provided to Veronica Serna.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2