306005633-2-15-2024-22-AS-MSTC-D2PSTX-20240222131014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005633
Report Date: 02/15/2024
Date Signed: 02/15/2024 10:15:00 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
11/03/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231103161201

FACILITY NAME:	MARYKNOLL SENIOR CARE		FACILITY NUMBER:	306005633
ADMINISTRATOR:	UMALI, FRANCES AMANDA		FACILITY TYPE:	740
ADDRESS:	531 WHITTEN WAY		TELEPHONE:	(805) 836-1556
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 5	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Frances Umali- Administrator		TIME COMPLETED:	10:16 AM

ALLEGATION(S):

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Facility lacked supervision resulting in resident sustaining multiple fractures.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced and met with Administrator Frances Umali for the purpose of delivering the findings into the above allegation. On November 3, 2023, the Department received the complaint, and the investigation was initiated by LPA Joseph Alejandre on November 6, 2023. LPA Alejandre obtained records pertaining to Resident #1 (R1) during the initial visit. The investigation completed by the Department revealed the following:

It is alleged that the facility lacked supervision resulting in the resident sustaining multiple fractures. Based on record review, R1 was admitted to the facility on August 14, 2019. The initial assessment for R1 documented the following conditions on the Physician’s Report dated August 23, 2019: Mild Cognitive Impairment, ambulatory without physical assistance, and requiring minimal assistance with their Activities of Daily Living (ADLs).

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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-20231103161201

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MARYKNOLL SENIOR CARE	FACILITY NUMBER: 306005633
	VISIT DATE: 02/15/2024

NARRATIVE

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Based on the interview, four out of the four staff indicated that R1 was provided and encouraged to use a walker however refused to use it, and the family member corroborated with this statement. Facility record shows R1 sustained injuries from two falls on October 17, 2022 and November 2, 2023. In between the one-year time frame, Staff #1 (S1) and the family member indicated that R1 had few minor slips from the chair or bed, however injuries were not sustained. The four other interviewed staff did not observe other falls.

On October 17, 2022, R1 suffered a mechanical ground-level fall in the facility bathroom and sustained a fractured elbow and was subsequently placed on a cast as per the UCI Health medical report dated November 14, 2023. R1’s cognitive functions began to decline, and the Physician’s Report was updated to reflect R1’s change of condition on October 23, 2023. On November 2, 2023, approximately 9:00am, R1 suffered a mechanical fall in the living room and sustained closed fracture of multiple ribs of right side, facial injury, and a laceration of forehead per the UCI Health medical report dated November 14, 2023. Staff #2 (S2) present at the time of the incident indicated that R1 was using a walker. Four staff and one resident interviewed also confirmed that S2 was present during the fall.

Based on the Department’s investigation, due to R1 being considered ambulatory from their most recent assessment dated October 23, 2023, and had not suffered from a fall or an injury for over one year, the evidence obtained did not support the allegation. In addition, the facility staff provided supervision and had taken appropriate measures to seek medical attention in a timely manner.

Therefore, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Frances Umali, and a copy of this report including the LIC9099C, and the LIC811s were provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

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