306003850-8-22-2023-22-AS-AORZ-CYAQTC-20231207112655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003850
Report Date: 08/22/2023
Date Signed: 08/22/2023 09:53:16 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
07/28/2022 and conducted by Evaluator Andrea Mendivil

COMPLAINT CONTROL NUMBER: 22-AS-20220728134559

FACILITY NAME:	WHISPERING OAKS - WAVERLY		FACILITY NUMBER:	306003850
ADMINISTRATOR:	IMELDA C. CARO		FACILITY TYPE:	740
ADDRESS:	14782 WAVERLY LANE		TELEPHONE:	(714) 931-1945
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY:	6	CENSUS: 6	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Imelda Caro - Licensee/Administrator		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Facility staff are not meeting resident's needs
Resident sustained an unstageable pressure injury due to negligence

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry by Administrator Imelda Caro and discussed the findings for the allegations listed above.

The Department received a complaint on 07/28/2022 and LPA Mendivil conducted initial 10-day visit on 08/02/2022. During the course of the investigation LPA Mendivil interviewed staff and residents as well as obtained copies of pertinent documents such as physician’s reports, admission agreements and medication records. Regarding the allegation facility staff are not meeting resident's needs and resident sustained an unstageable pressure injury due to negligence, the investigation revealed the following:

It was alleged that facility staff are not meeting resident’s needs. Based on interviews with 3 out of 6 residents indicated they believe that staff is taking good care of them and feels their needs are being met.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 22-AS-20220728134559

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: WHISPERING OAKS - WAVERLY	FACILITY NUMBER: 306003850
	VISIT DATE: 08/22/2023

NARRATIVE

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The other 3 residents were not available to be interviewed as 2 were sleeping and 1 was with visiting family. Interviews with 3 out of 3 staff denied allegations that the staff is not meeting resident’s needs.

Based on interviews with 3 out of 3 staff indicated they take care of the residents to the best of their ability. 3 out of 3 staff indicated they not yelled at a resident. 3 out of 3 staff reported that they have not been disrespectful to the residents.

Per review of Resident 1 (R1) physician’s report dated 03/17/2022 R1 entered the facility with a Stage 1 wound, and it was noted on hospital discharge paperwork that R1 would be discharged with home health to assist with wound care. 3 out of 3 staff indicated they did not see the wound getting worse. Based on review of the physician report R1 has a history of skin breakdown.

Therefore, based on the preponderance of evidence through record review and interviews the allegation Facility staff are not meeting resident's needs and resident sustained an unstageable pressure injury are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint.

No deficiencies cited.

An exit interview was conducted and a copy of this report this report was provided to facility administrator.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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