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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004289
Report Date: 05/21/2025
Date Signed: 05/21/2025 09:17:53 AM

Substantiated


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
12/13/2021 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20211213162011
FACILITY NAME:ST. FRANCIS HOME FOR THE ELDERLYFACILITY NUMBER:
306004289
ADMINISTRATOR:RUNETTE CATIBOG/OS SANTAFACILITY TYPE:
740
ADDRESS:5335 CANTERBURY DRIVETELEPHONE:
(951) 532-4644
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:6CENSUS: 6DATE:
05/21/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Anita De AlaTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Resident has multiple pressure injuries, including at least one unstageable pressure injury.
INVESTIGATION FINDINGS:
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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above for the purpose of delivering findings. LPA met with Staff Anita De Ala and explained the purpose of the inspection. Adminstrator (AD) Runette Catibog was contacted by phone at 8:55 a.m.

During the course of the investigation, interviews were conducted with Licensee Osvaldo “Oz” Santa Ana, AD, staff, and witnesses. By all accounts, Resident 1 (R1) had a prior working relationship with Licensee and AD, as R1’s sister had been a previous resident at the facility before passing away. Prior to October 11, 2021, R1 was still living at home and on October 11, 2021, R1 was admitted into the facility. At the time of R1’s arrival to the facility, they did not have any ulcers or redness on their Coccyx area and only had a small sore to their left toe. After about a month, R1 began to exhibit fits of anger toward staff and would not cooperate with being moved for regular rotation and cleaning. (Cont.LIC9009-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
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 4
Control Number 22-AS-20211213162011
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: ST. FRANCIS HOME FOR THE ELDERLY
FACILITY NUMBER: 306004289
VISIT DATE: 05/21/2025
NARRATIVE
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Staff would contact R1’s Responsible Party (RP) often, who would then come to the facility to try and calm R1 to get them to comply with staff. At one point during an outburst of anger, R1 punched a staff member in the abdomen. During their interview, AD stated that is when R1 developed some redness on their buttocks area. AD stated R1’s RP was notified about the change in demeanor and the redness, and R1’s RP informed AD they would talk with R1’s doctor.

Per Green Meadows Home Health Care Medical Records dated November 3, 2021, Home Health did an initial interview and check of R1 and found no skin injuries or problems on November 3, 2021. On November 22, 2021, the Home Health nurse noticed redness around the Coccyx region and instructed facility staff to rotate R1 more often in order to avoid a skin ulcer. On December 6, 2021, Home Health came to the facility again to check R1’s wound. R1 became combative and would not allow Home Health nurse to inspect their Coccyx area.

On December 9, 2021, R1’s RP contacted R1’s doctor who instructed R1 be transported via 911 to the hospital. Upon arrival at the hospital R1’s injury of an unstageable ulcer was discovered. During their interview, R1’s RP stated they were very involved with the care R1 was receiving while at the facility. R1’s RP stated they would be informed of R1’s verbal and physical outburst, and their resistance in allowing staff to provide care. Per R1’s RP, they asked R1 not be transported to the Veterans Affairs (VA) hospital or by emergency ambulance if avoidable. R1’s RP stated they did not want R1 to go to the VA hospital for care for personal reasons and did not want R1 to be transported by ambulance to limit expenses that are associated with emergency care. Per R1’s RP, both they and the facility could have made better decisions for R1’s care. R1’s RP stated staff at the facility did their best to assist R1 and to comply with their requests but subsequently caused delay in care that would have helped prevent R1 from developing an unstageable pressure injury.

During their interview, AD stated they attempted to have R1 transported to the hospital when their mental status changed, and R1 showed redness to his Coccyx area, however, R1’s RP convinced AD to delay in transporting R1 for personal and financial reasons. Per AD, although they felt otherwise, they conceded with RP’s requests. (Cont. LIC9099-C)
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20211213162011
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: ST. FRANCIS HOME FOR THE ELDERLY
FACILITY NUMBER: 306004289
VISIT DATE: 05/21/2025
NARRATIVE
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Based upon staff interviews, and record review of associated medical records there is evidence to corroborate the allegation that R1 developed an unstageable pressure injury due to Neglect/Lack of care and supervision. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations. (see LIC9099-D) and an Immediate $500 Civil Penalty is being assessed (see LIC421IM). Additional Civil Penalty is pending determination as per Health & Safety Code 1569.49(f).

An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20211213162011
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: ST. FRANCIS HOME FOR THE ELDERLY
FACILITY NUMBER: 306004289
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2025
Section Cited
CCR
87464(f)(6)
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Basic Services
(f) Basic services shall at a minimum include:
(6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services
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AD stated staff training regarding basic services and arrangements to meet residents' health needs including arranging transportation will be conducted and proof will be provided to LPA via email by POC date.
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Based on staff interviews, the licensee did not comply with the section cited above as medical treatment for R1 was delayed, resulting in R1 developing an unstageable pressure injury, which poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4