336411237-4-17-2023-18-AS-EMAN-CRAUS5-20230427154946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336411237
Report Date: 04/17/2023
Date Signed: 04/17/2023 09:55:33 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2020 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201106164914

FACILITY NAME:	HAPPY NEST		FACILITY NUMBER:	336411237
ADMINISTRATOR:	CLAIRE ITCHON		FACILITY TYPE:	740
ADDRESS:	3140 E. VISTA CHINO		TELEPHONE:	(760) 318-9973
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92262
CAPACITY:	6	CENSUS: 6	DATE:	04/17/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Jose Itchon- Caregiver		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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Staff caused injury to resident.
Resident suffered a fall resulting in injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Ryan Gardner and Mary Rico conducted an unannounced visit to the facility to deliver findings for the above complaint allegations. LPA met with Caregiver Jose Itchon and explained the reason for the visit.

The investigation was initiated on 11/10/2020 which consisted of interviews and file review revealed the following:

For allegation, Resident suffered a fall resulting in injuries:

It was alleged that R1 suffered a fall on 11/5/2020 that sustained injuries to their arm.

During interviews conducted with staff S1, S1 stated that they heard a loud noise coming from R1’s bedroom on 11/5/2020 around 3:00am. S1 went to R1’s bedroom to investigate the noise.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

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 18-AS-20201106164914

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HAPPY NEST	FACILITY NUMBER: 336411237
	VISIT DATE: 04/17/2023

NARRATIVE

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S1 found that R1 had fallen and was caught on the right side of the bed and the left side/stomach of R1’s body was on the floor. S1 found minor injuries to R1’s arms. S1 called R1’s hospice nurse immediately to address the situation. R1’s responsible party was called and informed of R1’s fall. R1’s responsible party lives outside the state of California so as a precaution the responsible party called the police to check on R1. When police and hospice arrived, they did not note major injuries. Hospice cleaned the wound and applied dressing to the wound.

During interview with R1’s responsible party, LPA discovered R1’s responsible party was immediately informed of R1’s fall and police were only called as a precaution due to the responsible party living outside of the state of California. R1’s responsible party noted that they did not have any suspicions of elder abuse towards R1, and they were satisfied with the care being provided to R1.

During document review, LPA found that the facility submitted a special incident report to state licensing detailing R1’s fall on 11/5/2020. The report included the police report number and the same recollection of events that was provided in the interview with facility staff.

For allegation, Staff caused injury to resident:

Based on the information gathered on the allegation of the resident suffered a fall resulting injuries, LPA found that R1 did fall and sustain injures to their arm, but the injuries were not caused by a staff. The staff took the correct actions to help the resident during and after R1’s fall.

Based on the evidence found during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Caregiver Jose Itchon, along with a copy of the appeal rights.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

LIC9099 (FAS) - (06/04)

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