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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005436
Report Date: 04/15/2024
Date Signed: 04/15/2024 09:13:51 AM

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
08/24/2023 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230824145331
FACILITY NAME:VICTORIA VILLA HOMEFACILITY NUMBER:
306005436
ADMINISTRATOR:OLTEANU, CLAUDIAFACILITY TYPE:
740
ADDRESS:11132 FRALEY STREETTELEPHONE:
(949) 232-9619
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 6DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Edna Jose, CaregiverTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Facility failed to to seek timely medical treatment
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Caregiver Edna Jose and explained the reason for the visit.

During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including Individual Program Plan, Physician Report and Garden Grove Hospital Medical Records. The purpose of today’s visit is to follow up on an investigation conducted by the Department regarding the above allegation. The investigation conducted revealed the following:

Resident 1 (R1) was admitted to the facility on April 1, 2020. Physician report dated March 09, 2023, notes that R1 had a diagnosis of intellectual disability, scoliosis, and cerebral palsy. R1 is marked as having motor impairment/paralysis and is wheelchair bound. R1 is non-ambulatory and unable to transfer themselves in and out of bed.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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-20230824145331
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: VICTORIA VILLA HOME
FACILITY NUMBER: 306005436
VISIT DATE: 04/15/2024
NARRATIVE
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On August 21, 2023, R1 was hospitalized at 9:58 AM per hospital admission records due to severe right leg pain. Hospital admission records reviewed note R1 reported right thigh pain with swelling for one week. R1 was determined to have a Periprosthetic fracture around their internal prosthetic right hip joint.

Per a behavioral assessment report dated April 1,2023, R1 is wheelchair bound and is at risk for falls due to refusing staff assistance and trying to get up from their wheelchair or maneuver their wheelchair without supervision. The assessment notes R1 is very unsteady on their feet when they are bearing weight on their legs and can only stand briefly with staff assistance. There are times when R1 needs two staff assist for transfers due to being uncooperative. R1 is reported to have multilevel disc degeneration in their back and neck. Additionally, R1 has hip pain and osteoarthritis in their leg and previously under went a hip replacement surgery.

During an interview with R1’s Regional Center of Orange County Service Coordinator (SC), it was noted a serious incident report (SIR) was submitted dated August 21, 2023, in which the facility reported R1 had reported having leg pain as early as August 18, 2023. When interviewed, the Licensee stated they had written the wrong date on the report and stated they became aware of R1’s pain on August 21, 2023 when staff brought it to her attention.

Per interview conducted with Staff 1 (S1), R1 began expressing pain on August 20, 2023, while assisting them in the shower. S1 administered over the counter Tylenol and placed R1 in their wheelchair. S1 described R1 okay and as good. The following day, S1 reported assisting R1 with another shower. During the shower R1 did not express any pain or discomfort. S1 stated it was not until R1 was brought to the breakfast table that Staff 2 (S2) noticed swelling on R1’s thigh. S2 took a photograph of R1’s thigh and sent it to the facility Administrator informing them R1 needed to go to the hospital. S2 drove R1 to the hospital themselves and was later met there by the Licensee.

An interview was attempted with R1, but unable to complete due to cognitive barriers.

Therefore, based on interviews conducted and documents reviewed, the allegation that Facility failed to seek timely medical treatment is deemed Unfounded, meaning the allegation was false, could not have happen or is without reasonable basis. We therefore dismissed the complaint.

An exit interview was conducted, and a copy of this report and confidential names list was provided at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2