306005575-2-6-2023-22-AS-AORZ-CNW23Q-20230209160241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005575
Report Date: 02/06/2023
Date Signed: 02/06/2023 12:59:24 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
01/10/2023 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20230110111813

FACILITY NAME:	ROSE GARDEN VILLA		FACILITY NUMBER:	306005575
ADMINISTRATOR:	OLTEANU, CLAUDIA		FACILITY TYPE:	740
ADDRESS:	2210 W AVALON AVE		TELEPHONE:	(949) 232-9619
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92706
CAPACITY:	6	CENSUS: 3	DATE:	02/06/2023
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Mylene Manze		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Licensee retained the resident with unstageable pressure injury
Licensee did not meet residents needs

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Kimberly Lyman and Alvaro Ramirez conducted an unnanounced complaint visit to deliver findings on the above allegations. LPAs was greeted and granted entry into the facility by Caregiver Judy Rivas Plata and explained the reason for the visit. Administrator Claudia Olteanu was present via telephone. Caregiver Mylene Manze arrived during the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report and hospital paperwork. Regarding the allegations that Licensee did not meet residents needs and Licensee retained the resident with unstageable pressure injury, the investigation revealed the following: Resident 1 (R1) is non-ambulatory and diagnosed with Peripheral Vascular Disease, (PVD). R1 has a history of chronic pressure injuries per Kaiser Permanente (KP) Hospital paperwork. Per facility documentation, the following timeline occurred: On 12/18/2022, Administrator contacted KP for a televisit regarding the worsening of resident's chronic pressure injuries. KP scheduled a visit with a wound doctor for 01/06/2023. Per Administrator, home health was requested and denied. On 12/19/2023, Administrator took the resident to KP CONTINUED ON LIC 9099C DATED 02/06/2023

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

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-20230110111813

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: ROSE GARDEN VILLA	FACILITY NUMBER: 306005575
	VISIT DATE: 02/06/2023

NARRATIVE

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emergency room after concerns regarding the pressure injuries were not adequately addressed by KP. Per hospital discharge paperwork dated 12/19/2022, R1 was seen for skin and rectal problems and a pressure injury of sacrum, stage 2. Resident was sent home same day with instructions on repositioning the resident and a reminder of wound care appointment on 01/06/2023. On 12/26/2022, Administrator contacted KP for a televisit regarding the wounds. No wound follow up by KP on this date. On 01/02/2023, Administrator submitted a request through the scheduling system for an appointment to address the pressure injuries. Administrator states no response from KP. On 01/05/2023, Administrator submitted once again for an appointment indicating the pressure injuries as reason for appointment. KP response was to remind Administrator of upcoming appointment on 01/06/2023. Administrator then took resident to KP emergency room again on 01/05/2023 where the resident was finally admitted. Hospital paperwork indicated the resident "has chronic ulcers of the shin and heels bilaterally which have not acutely changed. No new swelling, redness or discharge." Paperwork indicated seven wounds with two being unstageable. The wound on the left medial and lateral heel and right lateral malleolus ankle are deemed unstageable. Resident was admitted to the hospital from 01/05/2023-01/10/2023 and then transferred to a skilled nursing facility for further treatment. Administrator and staff indicate home health nurse not affiliated with KP was assisting facility with wound care. Home Health nurse indicates seeing the resident daily for approximately 10 days before hospitalization. Per Johns Hopkins medicine, patients with PVD have an increased risk of non-healing pressure injuries especially on the ankles and heels. Four out of four witnesses state Administrator was actively trying to get treatment for resident. Administrator denies any knowledge of pressure injury staging and indicates difficulty getting any information from KP regarding the resident's status. 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. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC9099 (FAS) - (06/04)

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