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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005247
Report Date: 07/26/2021
Date Signed: 07/30/2021 10:38:48 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
06/15/2021 and conducted by Evaluator James August
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210615155142
FACILITY NAME:FULLERTON PLAZA GUEST HOMESFACILITY NUMBER:
306005247
ADMINISTRATOR:MANGURAY, SEANFACILITY TYPE:
740
ADDRESS:3931 MADONNA DRIVETELEPHONE:
(657) 378-9603
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:6CENSUS: 4DATE:
07/26/2021
UNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Gerald Dia, AdministratorTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Facility is not kept clean
Resident has a pressure injury
Facility indoor temperature is too hot
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jim August made an unannounced complaint visit to complete the investigation on the above allegations. LPA was greeted and granted entry by Administrator Gerald Dia. LPA August explained the reason for the visit.

Upon entry to the facility LPA observed the indoor temperature to be 78 degrees F with the central air conditioning on as well as ceiling fans. LPA toured the physical plant and found it to be clean and free of debris. Resident rooms had individual air conditioning units. LPA toured the backyard and found it clean and free of debris. The kitchen was clean and there were no dirty dishes.

On June 21, 2021, LPA August interviewed Administrator Gerald Dia, Staff 1 (S1) and three residents (R1, R2, R3). Administrator Dia stated that R1 was on hospice care prior to residing at the facility. Dia stated that the resident developed a small, stage 1 pressure injury and the staff immediately attended to the injury as well as informing the hospice care staff at Cadence Hospice. Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: James August
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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-20210615155142
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: FULLERTON PLAZA GUEST HOMES
FACILITY NUMBER: 306005247
VISIT DATE: 07/26/2021
NARRATIVE
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Cadence Hospice ordered a DME bed to assist the resident in healing the stage 1 pressure injury. Per Dia, the bed arrived and was set up incorrectly by Cadence Hospice and the pressure was set too high. By the time Dia noticed the pressure settings he lowered the settings and informed Cadence Hospice who came to the facility and lowered the pressure further. Dia claimed that the staff were in fact repositioning R1 every 2 hours as well as making sure R1 did not sit in soiled diapers/clothes.

On June 21, 2021, LPA August interviewed S1. S1 stated that the facility always has air central air conditioning as well as individual room air conditioners. There is no requirement to keep the AC off and the facility is always comfortable. In addition, S1 stated that the facility is always kept clean. Furthermore, S1 stated that she cared for R1 and repositioned R1 and kept R1 dry as was instructed from Administrator Dia and Cadence Hospice. S1 stated that the hospice staff never once told her she was doing anything wrong.

On June 21, 2021, LPA August interviewed R1, R2 and R3. R1 stated that S1 or another staff member usually turns her and attends to her every 2 hours or so. She is never kept soiled for long and if she needs anything the staff are quick to help her. The facility temperature is fine and she had no issues or complaints with how she is being cared for. R2 stated that the caregivers at the facility are very attentive to her needs. Her room temperature is always kept comfortable and the facility is kept clean. R3 stated the facility is kept clean and he is free to use his room air conditioning as much as he wants.

On July 26, 2021, LPA August interviewed Cadence Hospice staff S2. S2 stated that the facility was not repositioning R1 every 2 hours or ensuring that the R1 was kept dry and free from soiled diapers. As a result, R1 developed a stage 1 pressure injury at the facility that continued to develop into a stage 2 injury. S2 confirmed that Cadence Hospice ordered a DME bed for R1 to assist in healing the pressure injury and that the bed was setup incorrectly with a pressure setting that was too high but claims that this would not cause or hamper the R1's ability to heal from the pressure injury.

As such, there is insufficient evidence to corroborate whether the above allegations have occurred. With the information obtained through the means described above, we have found the above allegations unsubstantiated. Although the allegations may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator Dia and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: James August
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2