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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006189
Report Date: 12/23/2024
Date Signed: 12/23/2024 09:37:45 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
09/06/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230906160954
FACILITY NAME:KAEGO'S RICHMAN GARDENSFACILITY NUMBER:
306006189
ADMINISTRATOR:HARVEY, LUPEFACILITY TYPE:
740
ADDRESS:317 N. RICHMAN GARDENSTELEPHONE:
(213) 478-0460
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY:26CENSUS: 24DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Rosie Maldonaldo and Maggie SanchezTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident wandering away from facility and causing resident to sustain multiple fractures and injuries.
Staff do not respond to facility alarm.
Staff does not securely lock facility's exterior gate.
Staff did not provide resident's authorized representative with the correct information of incident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Rosie Maldonado and explained the reason for the visit.
During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including Physician Report and UCI Medical Records. The purpose of today’s visit is to deliver the findings regarding the above allegations. The investigation conducted revealed the following:
Resident 1 (R1) was admitted to the facility on July 14, 2023, and has a diagnosis of Alzheimer’s disease with confusion and sundowning behavior per Physician report dated April 4, 2023. Per Physician report resident is not able to leave the facility unassisted.
On August 26, 2024, facility staff informed R1’s family that R1 was put to bed around 8:30 PM and fell in the back patio of the facility. However; surveillance video from the nearby liquor store showed R1 walking outside the facility at 8:28 PM while alone. CONT ON LIC 9099C DATED 12/23/2024
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
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 4
Control Number 22-AS-20230906160954
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: KAEGO'S RICHMAN GARDENS
FACILITY NUMBER: 306006189
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2024
Section Cited
CCR
87464(f)(1)
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Basic Services- Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This req is not being met as evidenced by:
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Licensee to provide retraining on basic services and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure R1 received appropriate care and supervision resulting in R1 eloping and sustaining multiple injuries including a fractured jaw. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.
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Type A
12/24/2024
Section Cited
CCR
87207
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False Claims- No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This req is not being met as evidenced by:
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Licensee to read the regulation and provide a statement of understanding to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure employees did not make false claims regarding R1’s fall. Two caregivers confirmed providing false statements to R1’s family which was which was confirmed by R1’s family. This poses an immediate health and safety risk to 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 22-AS-20230906160954
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: KAEGO'S RICHMAN GARDENS
FACILITY NUMBER: 306006189
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2024
Section Cited
CCR
87705(j)
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Care of Persons with Dementia- The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:
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Licensee to conduct an in-service on elopements and forward proof to LPA by POC due date.
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Based on interviews conducted, Two of two staff confirmed auditory alarms are turned off and one staff reported alarms are difficult to hear resulting in R1 elopement and subsequent injuries. This poses an immediate health and safety risk to residents in care.
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Type A
12/24/2024
Section Cited
CCR
87705(h)
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 Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement was not met as evidence by:
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Licensee to provide an in-service to staff regarding resident safety and foward proof to LPA by POC due date.
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Based on interviews conducted, Two of two staff reported observing staff propping open exterior leading gates for ease of access, thus, incapacitating the ability to self close and latch. This poses an immediate risk to safety to 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20230906160954
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: KAEGO'S RICHMAN GARDENS
FACILITY NUMBER: 306006189
VISIT DATE: 12/23/2024
NARRATIVE
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The liquor store manager confirmed seeing R1 walking outside of the facility the night of incident. Staff interviewed reported last seeing R1 at around 8 PM and did not see them again until approximately 9:20 PM when R1 was brought back by an unknown stranger. Staff had failed to notice R1 was missing during this time. One of two staff on duty that day admitted staff often turn off the auditory alarm to the emergency exit door located in the building and confirmed the alarm to the door was turned off at the time of R1’s elopement. One of two staff interviewed reported it being difficult to hear alarms due to the noise levels and location of R1’s bedroom. The facility is not approved for a locked perimeter exterior, however, two of two staff interviewed reported observing other staff propping the gates open for easy access in and out of the facility.
R1’s family arrived at the facility at approximately 9:30 PM. Upon arriving R1’s family stated R1 had major bruising to their face, chest, hands and arms in addition to having a front right tooth completely knocked out, left front tooth loose and bottom teeth sore and cracked.

After consulting with R1’s hospice nurse, 9-1-1 was called. R1 was taken to UCI Medical Center due to the severity of injuries sustained where they were admitted at 11:14 PM and diagnosed with bruising to the chin, tooth avulsion and maxillary ridge fracture of the mouth, blunt trauma to the torso, organ injury and cardiac contusion and a skull fracture. A meeting was held with facility management and R1’s family where it was disclosed that R1 had actually fallen outside of the facility grounds and an unknown man had brought them back to the facility despite initially saying the fall occurred at the facility. Two of two staff confirmed lying to R1’s family and that they were pressured to do so by the facility management. R1’s family reported management admitted to lying regarding the circumstances of R1’s fall during their meeting.

Therefore, based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegations that staff did not provide adequate supervision resulting in resident wandering away from facility and causing resident to sustain multiple fractures and injuries; Staff did not provide resident’s authorized representative with the correct information of incident; Staff do not respond to facility alarm; and Staff does not securely lock facility's exterior gate has been Substantiated.

The facility is being cited per Title 22, Division 6 of the California Code of Regulations.

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f)

An exit interview was conducted, and a copy of this report, 9099-D Page, and appeal rights was left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4