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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004515
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:11:07 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
07/17/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230717103000
FACILITY NAME:HOUSE AT VINEWOODFACILITY NUMBER:
306004515
ADMINISTRATOR:LINDA P. BOLIVARFACILITY TYPE:
740
ADDRESS:17382 VINEWOOD AVENUETELEPHONE:
(714) 486-1810
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:6CENSUS: 3DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Linda BolivarTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Facility does not follow the resident's hospice care plan
Facility does not provide adequate care to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as physician report and hospice notes. Regarding the allegations that facility does not follow the resident's hospice care plan and facility does not provide adequate care to resident, the investigation revealed the following: Resident 1 (R1) is on hospice with a stage 4 pressure injury on the coccyx. Interviews conducted with staff and hospice nurse indicate hospice is coming to the facility every other day to conduct wound care. Staff indicated being shown how to provide wound care visually to resident in-between hospice visits. All staff interviewed state there was no written instructions for wound care. Five out of five staff state providing wound care as instructed and turning the resident every 2 hours. Interviews conducted indicated that R1 is at end of life and not eating therefore preventing the wound from healing. CONTINUED ON LIC 9099C DATED 08/10/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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-20230717103000
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: HOUSE AT VINEWOOD
FACILITY NUMBER: 306004515
VISIT DATE: 08/10/2023
NARRATIVE
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Due to conflicting information, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2