306006404-3-19-2025-22-AS-SSAS-DF7W3W-20250328165635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006404
Report Date: 03/19/2025
Date Signed: 03/19/2025 03:42:43 PM

Unsubstantiated

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
03/06/2024 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240306093154

FACILITY NAME:	COAST SENIOR CARE, 1		FACILITY NUMBER:	306006404
ADMINISTRATOR:	VIANA, KRISTEN		FACILITY TYPE:	740
ADDRESS:	19861 CARMANIA LN		TELEPHONE:	(714) 470-0194
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92646
CAPACITY:	6	CENSUS: 4	DATE:	03/19/2025
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Mitzi Avena		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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• Facility did not inform the resident’s representative of the change of conditions.
• Facility neglected to identify the resident’s change of condition.
• Resident sustained a stage 4 pressure injury.
• Facility did not seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrived at facility and was greeted at the door by caregiver and granted entry. LPA spoke with mitzi Avena and explained the purpose of the visit.

The complaint was investigated by the Department. Findings are based upon this investigation which included records review, interviews with the following: 3 staff, 5 witnesses, and 2 residents, medical records from Senior Care Mobile Doctor, and Mission Home Care.
It is alleged facility did not inform the resident’s representative of the change of conditions. Interview with 2 of 2 staff revealed the only change of condition that resident (R1) had was in November of 2023 and it was due to behavior change. Staff indicated that the change was reported to the Administrator as per protocol and Administrator informed R1’s representative. Administrator stated when R1’s behavior changed at times,
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240306093154

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: COAST SENIOR CARE, 1	FACILITY NUMBER: 306006404
	VISIT DATE: 03/19/2025

NARRATIVE

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resident’s authorized representative would have to be called multiple times to assist with R1’s behavior.

It is alleged that facility neglected to identify the resident’s change of condition. Interview with 2 of 2 staff revealed that they observed R1 to have a change in behavior in November of 2023. Staff stated that they did not observe resident to have any other change of condition. Staff indicated that they did not observe a change in R1’s physical appearance to be able to identify a change of condition. Staff gave R1 a shower on a daily basis that included a visual body check, and no changes were noted as well.

It is alleged that resident sustained a stage 4 pressure injury. Interview with 2 of 2 staff revealed that there was no skin tear or wound on R1. R1 was on a daily shower schedule where body checks were conducted by staff and no skin tear, no wound, no redness, or mal odor was observed. Records from Senior Care indicate that the physician’s assistant on February 6, 2024, first learned that R1 had a stage 4 ulcer. However, records indicate that a visit was done on January 4, 2024, and January 5, 2024, with no mention of an ulcer. R1 was moved out of the facility on December 31, 2023. Interview with Senior Care physician’s assistant revealed that R1 had been under their care since prior to December 31, 2023. A visit was done with R1 on March 4, 2024, in which it was observed R1’s health was declining and that was the first time it was learned that R1 had an ulcer. Physician’s assistant had two prior visits before February 6, 2024, and was not aware or informed of an ulcer. Interview with private caregiver revealed that they had cleaned R1 in their bed and changed their diaper the day R1 was removed from the facility and did not observe any redness or a wound and no odor.

Based on the information gathered by the department during the investigation, there was not enough evidence to corroborate the following allegations: facility did not seek medical attention in a timely manner, facility did not inform the resident’s representative of the change of conditions, facility neglected to identify the resident’s change of condition and resident sustained a stage 4 pressure injury.

Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

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