<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005839
Report Date: 04/15/2024
Date Signed: 04/15/2024 04:02:03 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
06/14/2022 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-NP-20220614113619
FACILITY NAME:TUSTIN SENIOR HOMEFACILITY NUMBER:
306005839
ADMINISTRATOR:ANCA, ANAFACILITY TYPE:
740
ADDRESS:1732 LANCE DRTELEPHONE:
(714) 730-8043
CITY:TUSTINSTATE: ZIP CODE:
92780
CAPACITY:6CENSUS: 5DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Teresa Cerino, CaregiverTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not meeting resident's needs
Facility retained a resident with an unstageable pressure injury
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Teresa Cerino, Caregiver and discussed the reason for the visit.

The Department received a complaint on 06/14/2022 and the initial 10 day visit was conducted on 06/23/2022. During the course of the investigation the LPA interviewed residents, staff and witnesses and obtained copies of emergency contact information, physicians' reports, hospital discharge paperwork and admission agreeement. The complaint alleges that the facility staff are not meeting resident's needs and facility retained a resident with an unstageable pressure injury, the investigation revealed the following:

It is alleged the faciltiy staff are not meeting resident's needs. Based on observations of residents, the residents all appeared well groomed and during the initial visit LPA witnessed the residents having lunch.
CONT ON 9099- C DATED
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
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 2
Control Number 22-NP-20220614113619
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: TUSTIN SENIOR HOME
FACILITY NUMBER: 306005839
VISIT DATE: 04/15/2024
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
Based on interviews with 3 out of 6 residents they reported that the facility takes care of them but 2 out of 6 reported they do not have activities for the residents. 3 of the residents were unable to be interviewed as 1 resident was hard of hearing, 1 resident was bedridden and asleep and the final resident was not oriented to time and space.

Based on interviews with 3 out 6 residents stated they are put to bed around 7 pm, but they are not required to sleep. Based on interviews with 3 out of 3 staff indicate that the staff is available at all hours of the day and the facility utilizes a call system which is taken to staff's room at bed time.

Per review of physician report dated 05/25/2022 stated that Resident 1 (R1) had a Stage 2 wound on their coccyx, no mention of any other wound. Per interviews with Licensee/Administrator Adela Albu, Adela stated that R1 only had 1 pressure injury at time of admission.

Therefore, based on the preponderance of evidence through records reviewed and interviews the allegations that facility staff are not meeting resident's needs and facility retained a resident with an unstageable pressure injury are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint.

No deficiencies cited.

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

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

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2