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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005983
Report Date: 03/01/2023
Date Signed: 03/01/2023 10:23:29 AM

Substantiated


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
02/24/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230224135054
FACILITY NAME:LA PALMA HOMECAREFACILITY NUMBER:
306005983
ADMINISTRATOR:BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:1418 W LA PALMA AVETELEPHONE:
(714) 833-5911
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 4DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Janet Infante and Jimmy InfanteTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure catheter irrigation was performed appropriately by a skilled professional for resident in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Lyman conducted the initial 10 day complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report and staff training. Regarding the allegation that staff did not ensure catheter irrigation was performed appropriately by a skilled professional for resident in care, the investigation revealed the following: Resident 1 (R1) has a suprapubic catheter. On 02/24/2023, R1's family friend transported R1 to Anaheim Regional Hospital after S1 had irrigated the resident's catheter. Per witness, R1 was treated at the emergency room for the clogged catheter and remained on antibiotics from a prior urinary tract infection. S1 admits to assisting resident with irrigating the catheter and states had catheter training with prior employment. S1 is not a licensed professional and there is no proof of catheter training at the facility. Documentation of St. Joseph Home Health Agency services indicate home health was terminated 02/24/2023 and services were for physical, occupational, and speech therapy. CONT ON LIC 9099C DATED 03/01/2023
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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 3
Control Number 22-AS-20230224135054
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: LA PALMA HOMECARE
FACILITY NUMBER: 306005983
VISIT DATE: 03/01/2023
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
LPA did not observe any care plan from physician or home health agency for catheter management. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted with facility representative and a copy of this report was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20230224135054
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: LA PALMA HOMECARE
FACILITY NUMBER: 306005983
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2023
Section Cited
CCR
87623(a)(A)
1
2
3
4
5
6
7
The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances: Irrigation shall only be performed by an appropriately skilled professional in accordance with the physician's orders. This req is not being met as evidenced by:
1
2
3
4
5
6
7
Licensee to provide care plan to LPA indicating catheter care management for Resident 1 by POC due date.
8
9
10
11
12
13
14
Based on interviews conducted, Licensee failed to ensure R1's catheter was irrigated by an appropriately skilled professional. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3