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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005991
Report Date: 11/18/2024
Date Signed: 11/18/2024 02:28:59 PM

Substantiated


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
08/27/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240827122914
FACILITY NAME:GARDEN GROVE GUEST HOME LLCFACILITY NUMBER:
306005991
ADMINISTRATOR:TISTOJ, RUTHFACILITY TYPE:
740
ADDRESS:12882 SHACKELFORD LANETELEPHONE:
(714) 430-3534
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:47CENSUS: 42DATE:
11/18/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Paige Rohrer, Wellness DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Unqualified facility staff are administering injections to residents
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the four allegations listed above. LPA was greeted and granted entry by facility wellness director Paige Rohrer after explaining the purpose of the visit.

An initial investigation visit took place on September 4, 2024. During the visit, LPA requested and obtained the facility census, staff roster, resident records for six admitted individuals including physician orders and medication administration records as well as reviewed the medication carts. Interviews with the facility's wellness director and administrator conducted.

During the present visit, LPA requested the facility census and staff roster. Resident and staff interviews were conducted along with a tour of the two hallways of the facility. Additional record requested and reviewed.

CONTINUED ON FORM LIC809-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
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 5
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
08/27/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240827122914

FACILITY NAME:GARDEN GROVE GUEST HOME LLCFACILITY NUMBER:
306005991
ADMINISTRATOR:TISTOJ, RUTHFACILITY TYPE:
740
ADDRESS:12882 SHACKELFORD LANETELEPHONE:
(714) 430-3534
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:47CENSUS: 42DATE:
11/18/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Paige Rohrer, Wellness DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Facility staff are not ensuring that medications are inaccessible to residents

Facility staff are not ensuring that residents are taking medications as prescribed

Facility staff are not meeting incontinence care needs of residents
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the four allegations listed above. LPA was greeted and granted entry by facility wellness director Paige Rohrer after explaining the purpose of the visit.

An initial investigation visit took place on September 4, 2024. During the visit, LPA requested and obtained the facility census, staff roster, resident records for six admitted individuals including physician orders and medication administration records as well as reviewed the medication carts. Interviews with the facility's wellness director and administrator conducted.

During the present visit, LPA requested the facility census and staff roster. Resident and staff interviews were conducted along with a tour of the two hallways of the facility. Additional record requested and reviewed.

CONTINUED ON FORM LIC809-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20240827122914
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: GARDEN GROVE GUEST HOME LLC
FACILITY NUMBER: 306005991
VISIT DATE: 11/18/2024
NARRATIVE
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CONTINUED FROM FORM LIC809-A
Regarding the allegation that Facility staff are not ensuring that medications are inaccessible to residents, the following has been concluded: During both unannounced facility visits, the two medication carts in use by facility staff were actively observed to be stationed at the med tech station in the facility and verified to be locked. No other medication was observed to be accessible outside of the secure central storage.

Regarding the allegation that Facility staff are not ensuring that residents are taking medications as prescribed, the following has been concluded: The facility uses an electronic medication administration records. Facility staff demonstrated the use of the software to keep track of prescription and administration status during the present visit. LPA additionally verified that there were no discrepancies between the centrally stored medication and the records for four randomly selected residents. No discrepancies or administration errors were found during the review.

Regarding the allegation that Facility staff are not meeting incontinence care needs of residents, the following has been concluded: Based on residents and staff interviews, facility observation and review of records conducted during the two facility visits, no instances of wet/dirty linen or articles of clothing were observed. There were also no occurrences of any lingering smells that could be associated with a failure to manage incontinence symptoms in residents during the visits. Individual care assignments for the previous two weeks were also obtained and reviewed and confirmed that adequate incontinence care is being provided and documented by staff.

As a result, the three allegations listed are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20240827122914
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: GARDEN GROVE GUEST HOME LLC
FACILITY NUMBER: 306005991
VISIT DATE: 11/18/2024
NARRATIVE
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CONTINUED FROM FORM LIC809
Regarding the allegation that Unqualified facility staff are administering injections to residents, the following has been concluded: Based on records reviewed, multiple residents admitted to the facility are diagnosed with insulin-dependent diabetes while also being assessed to be unable to self-monitor their glucose levels or self-inject insulin if necessary. The stated facility policy is to conduct hand over hand glucose monitoring and injections, however based on multiple staff and resident statements, injections are often conducted single-handedly by facility med techs. Title 22 restrictions for admission and retainer of residents with diabetes states that the facility may admit or retain residents with diabetes "if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional". Based on statements made during the visit, the restrictions are not met, therefore the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met.

A type B citation is issued on an attached form LIC809-D. An exit interview was conducted and a copy of this report along with attached citation and appeal rights were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240827122914
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: GARDEN GROVE GUEST HOME LLC
FACILITY NUMBER: 306005991
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2024
Section Cited
CCR
87628(a)
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Per CCR Section 87628(a) on Diabetes: "The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing (...), and is able to administer his/her own medication (...) or has it administered by an appropriately (...)
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Licensee intends to apply for a Department-issued waiver in order to continue providing care to its residents who have become unable to manage their condition independently.
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skilled professional.
This requirement is not met as evidenced by multiple statements indicated med tech staff are conducting injections personally rather than hand-on-hand. This constitutes a potential risk to the health, safety and personal rights of residents in care.
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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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5