Incident investigation·December 16, 2022

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz made an unannounced case management visit to follow up on an Incident report dated 12/11/2022 received in the Orange County Regional Office on 12/12/2022. LPA met with Licensee/Administrator (L/AD) Clara Han and explained the reason for the visit. Incident report dated 12/11/2022 indicated that on 12/10/22 on or about 8:41pm Resident 1 pressed facility call button with no response then called local fire department. Fountain Valley Fire Department (FVFD) arrived to the facility on or about 8:46pm with no staff present at the facility and six residents inside the facility. FVFD called Licensee/Administrator Clara Han on or about 8:46pm to discuss incident. Staff 1 (S1) and Staff 2 (S2) arrived to the facility between 8:50pm-8:55pm. During today's visit, LPA Quiroz along with (L/AD) Clara Han conducted tour of interior and exterior of facility premises. During today's visit, LPA Quiroz conducted interviews with Resident 3, Resident 4, Resident 5, Resident 6, Staff 1, Staff 2 and Licensee/Administrator Clara Han and reviewed documents for six of six residents but not limited to: Physician report, identification form and needs and services plan. Based on documentation review, four of six residents residing at the facility have a Dementia diagnose identified on their LIC 602 (Physician Report). LPA Quiroz provided consultation to Licensee/Administrator Clara Han and Facility staff regarding California Code of Regulation (CCR) Care of Persons with Dementia: 87705. Based on today's observations and documentation review, facility is being cited per Title 22,(CCR) Care of Persons with Dementia: 87705(c)(4). (c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4)There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. CONTINUED ON NEXT PAGE... This report was reviewed with L/AD Clara Han, and a copy of this report, Appeal Rights, LIC 809-D, LIC 811-Confidential Names and copy of CCR Care of Persons with Dementia-87705 were provided at exit.