306005385-12-28-2023-22-AS-SSAS-CYYNGC-20231229092649

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005385
Report Date: 12/28/2023
Date Signed: 12/28/2023 01:14:09 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
12/28/2020 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201228104338

FACILITY NAME:	ORANGE COUNTY CARE HOME II		FACILITY NUMBER:	306005385
ADMINISTRATOR:	RASSOULI ZADEHEI, FAHIMEH		FACILITY TYPE:	740
ADDRESS:	27561 ALMENDRA DRIVE		TELEPHONE:	(949) 322-1078
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	12/28/2023
		UNANNOUNCED	TIME BEGAN:	10:16 AM
MET WITH:			TIME COMPLETED:	11:59 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was severely dehydrated due to neglect
Staff did not ensure resident is being fed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding the complaint allegations above. LPA Haley was granted entry and explained the reason for the visit.

The complaint investigation consisted of a review of resident records, MemorialCare Saddleback Medical Center records, St. Rose of Lima Home Health records, interviews with facility staff, facility residents, Hospice and Home Health providers.

Regarding the allegations: Resident was severely dehydrated due to neglect and Staff did not ensure resident is being fed, during the investigation 10 of 11 individuals either denied the allegations and/or were unable to verify the allegations to be true. Interviews and record review reveal, on December 20, 2020, caregivers informed Licensee/Administrator Faith Rasouli Resident 1 (R1) had not eaten since December 19, 2020.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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 3

Control Number 22-AS-20201228104338

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: ORANGE COUNTY CARE HOME II	FACILITY NUMBER: 306005385
	VISIT DATE: 12/28/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Resident 2 (R2) was interviewed regarding the complaint allegations and R2 confirmed R1 would come to the table and eat with the rest of the residents. R2 stated the caregivers would give all the residents the same amount of food and something to drink.

Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations: Resident was severely dehydrated due to neglect and Staff did not ensure resident is being fed, occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, both allegations are deemed Unsubstantiated.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 22-AS-20201228104338

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: ORANGE COUNTY CARE HOME II	FACILITY NUMBER: 306005385
	VISIT DATE: 12/28/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Licensee/Administrator Rasouli contacted R1’s responsible party and informed them of the change in condition and requested to send R1 to the hospital due to the change in condition.

A review of MemorialCare Saddleback Medical Center records indicate Resident 1 (R1) was admitted December 20, 2020. R1 was assessed and active problems were discovered:

Pneumonia/COVID 19 (Principal Problem)
Acute respiratory failure with hypoxia
Senile dementia without behavioral disturbance
Oral phase dysphagia
Severe protein-calorie malnutrition
Encephalopathy due to COVID-19 virus
Pressure ulcer of left heel, unstageable

A review of MemorialCare Medical Center progress notes by Physician 1 (P1), dated December 22, 2020, stated the following: Patient has profound dysphagia unable to initiate eating and without demonstrated ability to swallow safely. This is likely the result of end stage dementia more so than COVID-19 infection though the latter is contributing. Dysphagia and disinterest in eating is a chronic process as witnessed by 25-pound weight loss since February 2020 and chronic hypernatremia that demonstrated insufficient free water intake. I advised patients [responsible person] that the patient is at the end of life. Treatment for COVID-19 was unlikely to turn around what has been a chronic and slow process that began before any infection.

Interviews with facility staff members, California Mission Hospice Nurse, and a home Health Nurse all revealed R1 was fed, and the resident’s appetite would vary. According to the Hospice Nurse, R1 was eating 80% – 90% of his meals. December 16, 2020, was the last time Hospice visited R1 and it was reported the resident was eating 60% - 70% of his meals. A Home Health Nurse revealed R1 had a good appetite, but R1 did lose weight due to his dementia diagnosis.

Continued on LIC9099C

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3