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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006247
Report Date: 11/22/2024
Date Signed: 11/22/2024 04:49:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
08/22/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20240822133857
FACILITY NAME:FAMILY CHOICE SENIOR LIVINGFACILITY NUMBER:
306006247
ADMINISTRATOR:JUNGE, PAMELAFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE AVENUETELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 22DATE:
11/22/2024
UNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Pamela Junge - AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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A lack of supervision resulted in resident leaving the facility unassisted.
INVESTIGATION FINDINGS:
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This unannounced investigation inspection by Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Fred Arias is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by facility staff. LPA met with Pamela Junge, Administrator and explained the nature of the inspection.

The department received a complaint on August 22, 2024 stating a lack of supervision resulted in resident leaving the facility unassisted. During the investigation, the Department interviewed the facility Administrator and reviewed resident documentation.

(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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 3
Control Number 22-AS-20240822133857
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306006247
VISIT DATE: 11/22/2024
NARRATIVE
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(continued from LIC9099)

On November 22, 2024, LPAs conducted a visit to the facility. LPAs obtained resident roster, personnel report, physician's report, hospital discharge paperwork, Individual Service Plan, daily health check log and preplacement appraisal.

LPAs reviewed hospital discharge paperwork. Per the discharge paperwork, Resident 1 (R1) was admitted to the hospital on August 21, 2024 due to "being found down in the street." The discharge paperwork goes on to say "Per EMS report, patient was found face down on the curb with possible seizure-like activity prior to EMS arrival." LPAs reviewed R1's Physician's Report dated June 3, 2024. Per physician's report, R1 is unable to leave the facility unassisted. LPA conducted an interview with Administrator. AD stated R1 left the facility unassisted. Based on records reviewed, LPAs determined a lack of supervision resulted in R1 leaving the facility unassisted.

The preponderance of evidence standard has been met. The allegations are determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that one violation occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240822133857
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FAMILY CHOICE SENIOR LIVING
FACILITY NUMBER: 306006247
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Administrator stated they will conduct an in-service training regarding supervision of residents and a review of functional capabilities of all residents for all facility staff by the assigned due date. LPA advised AD to document the training with the following information: date/time the training occurred,
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Based on record review, LPA determined R1 was found outside of the facility while seizing. R1 was transported to a hospital via EMS.
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participating staff and topics covered. AD stated they will email LPA all documentation for this training by the assigned Plan of Correction due date of December 9, 2024.
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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: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
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