306005385-12-28-2023-22-AS-SSAS-CYYNGB-20231229092648

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005385
Report Date: 12/28/2023
Date Signed: 12/28/2023 01:15:12 PM

Unfounded

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:	12:00 AM
MET WITH:	Faith Rasouli - Licensee/Administrator		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Staff did not notify resident's authorized representative of resident's change in health conditions.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding the complaint allegation above. LPA Haley was granted entry and explained the reason for the visit.
The complaint investigation consisted of a review of resident records, Memorial Care Saddleback records, St. Rose of Lima Home health records, interviews with facility staff, residents, Hospice and Home Health providers.

Regarding the allegation Staff did not notify resident's authorized representative of resident's change in health conditions.
It was discovered Licensee/Administrator Faith Rasouli was in contact with Resident 1’s (R1) responsible party regarding R1’s health in the days prior to R1 being sent to the hospital. Review of text messages between Administrator Rasouli and the responsible party reveal the two individuals were in regular contact regarding R1, visiting status of the facility, and the COVID-19 virus.
Continued on LIC9099C

Unfounded

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)

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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

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Text message review show Licensee/Administrator Rasouli would send routine updates regarding the spread of the Coronavirus, updates regarding visiting family members at the facility, and updates on R1's health. In a text message dated December 16, 2020, Licensee/Administrator Rasouli notified R1’s responsible party that R1's appetite was less than normal, R1 was quiet, and had a cough. The responsible party was informed R1’s physician was informed about R1’s recent change in condition. Additional text messages were exchanged regarding R1’s change in condition on December 18, 2020. After R1 was admitted to the hospital December 20, 2020, additional text messages were exchanged until December 22, 2020.

During a review of MemoriaCare Medical Center records, it was clear R1's responsible party was provided updates on R1 health during R1's entire time at the facility. According to a Nurse Practitioner (NP), R1’s responsible party stated, the patient (R1) is doing well at the board and care until February 2020 when R1 fell and fractured the right hip. R1 was sent to rehab until mid-March. R1 then went back to the board and care, was placed on hospice and was doing well. R1’s responsible party also agreed that after R1’s hospital visit, going back to the board and care with hospice would be best for the patient, after treatment is completed.

During an interview with a Nurse from California Mission Hospice, LPA Haley was informed that R1’s physician and family are notified after every visit. According to the Nurse, R1's last visit from California Mission Hospice was December 16, 2020.

Based on the information gathered during the investigation through interviews and document review, the allegation mentioned above is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

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

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)

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