Inspection Reports for
Hollybrook Senior Living of Orange

The facility was toured including physical plant, food service, and first aid kit. Resident rooms and common areas were found to be adequately equipped and maintained. Safety equipment such as smoke detectors, fire extinguishers, and emergency supplies were checked and found compliant. Resident files contained required documentation. No residents were on hospice during the visit. The inspection was ongoing with plans to return for continuation.

The complaint investigation was unannounced and addressed multiple allegations including failure to provide mail, medication mismanagement, resident harm prevention, housekeeping timeliness, safeguarding personal items, toileting assistance, inappropriate staff communication, and hand hygiene. The allegation regarding mail was unsubstantiated, while all other allegations were unfounded.

After interviews with residents and staff, observations, and record reviews, all allegations were determined to be either unsubstantiated or unfounded. Residents and staff reported generally adequate services, proper medication management, respectful communication, timely housekeeping and toileting assistance, safeguarding of personal belongings, and proper hand hygiene practices. No deficiencies were cited.

The complaint alleged that staff did not safeguard a resident’s personal belongings. The investigation found conflicting statements and evidence, including police records and room inspection, and concluded the allegation was unsubstantiated.

The investigation included interviews, room inspection, photographs, police records, and medical records. Conflicting information was found regarding missing items, and the allegation was deemed unsubstantiated due to lack of sufficient evidence.

The complaint alleged that the facility did not safeguard a resident's personal belongings. The investigation was unannounced and included interviews with staff and residents, a facility tour, and review of documentation. The allegation was found unsubstantiated due to conflicting information and lack of evidence.

The investigation revealed conflicting information regarding missing items; residents and staff denied theft, and documentation showed previous accusations were unsubstantiated. Due to lack of corroborating evidence, the allegation was deemed unsubstantiated.

The complaint investigation was triggered by allegations received on 09/12/2024 concerning unexplained injuries and falls due to lack of supervision and improper medication dispensing. The investigation included interviews with staff, review of medical and medication records, and police reports. The allegations were found unsubstantiated or unfounded.

The investigation found the allegations of lack of supervision leading to unexplained injuries and falls to be unsubstantiated due to insufficient evidence. The allegation regarding medication administration was deemed unfounded after review of medication orders and interviews.

The complaint involved Resident 1 who was sent out on a 5150 psychiatric evaluation after allegedly making threats to kill everyone in the facility. The resident was evaluated and referred for a hold and has not returned to the facility.

The facility appeared clean, safe, and sanitary during the visit. The resident involved in the incident was sent to a medical center and had not returned. No deficiencies or violations were noted during the visit.

The facility appeared clean, safe, and sanitary during the visit. Residents were observed relaxing and eating lunch. The incident involved a resident with a psychiatric hold who has not returned to the facility.

The complaint alleged illegal eviction. The investigation revealed that Resident 1 was served an eviction notice on 04/17/2024 for alcohol usage in violation of house rules. The department approved the eviction notice as legal. The allegation was deemed unfounded.

The investigation found that the eviction notice served to Resident 1 for violation of house rules related to alcohol usage was legal and approved by the department. The allegation of illegal eviction was deemed unfounded based on interviews and record review.

The complaint investigation was initiated based on allegations received on 04/18/2024. The allegations included staff not assisting residents with dining needs, inadequate activities, and failure to assist with toileting needs. The dining and activities allegations were unfounded, while the toileting allegation was unsubstantiated.

The investigation found the allegations regarding dining assistance and activities to be unfounded, with residents confirming receipt of lunch and participation in activities. The allegation regarding toileting assistance was deemed unsubstantiated due to conflicting information and lack of evidence.

The complaint involved allegations that staff did not provide a resident an admission agreement, staff yelled at a resident, and staff threatened a resident. The admission agreement allegation was unfounded. The yelling and threatening allegations were unsubstantiated due to conflicting statements and insufficient evidence.

The investigation found the allegation that staff did not provide a resident an admission agreement to be unfounded based on documentation and interviews. The allegations that staff yelled at or threatened a resident were deemed unsubstantiated due to conflicting information and lack of sufficient evidence.

The complaint alleged that staff did not follow proper eviction procedures. The allegation was investigated and found to be unfounded.

The investigation revealed that Resident 1 moved out voluntarily with family on 02/24/2024 despite providing a 30-day notice via text message. Interviews and documentation confirmed the resident was not evicted and was satisfied with the move. The allegation was deemed unfounded.

The complaint investigation was unannounced and addressed allegations including involuntary 72-hour hold placement, timely provision of keys, provision of activities, and restriction of resident leaving the facility. The allegations were found to be unfounded or unsubstantiated based on interviews, record reviews, and observations.

The investigation found that the resident was appropriately placed on a 72-hour hold due to grave disability, keys were replaced timely, activities such as bingo, music therapy, and cooking classes were provided, and residents were not restricted from leaving the facility. Additional allegations regarding facility rules and resident records were unsubstantiated due to conflicting information.

The complaint was unsubstantiated due to lack of sufficient evidence to prove the alleged violations occurred.

The investigation found adequate food supply and warm food delivery processes. Six out of seven residents reported food was served warm and dinner delivery times were generally between 4-5 PM, with personalization available. Communication issues were denied by six out of seven residents and not observed by the investigator. Due to conflicting information, the allegations were deemed unsubstantiated.

The complaint investigation was triggered by multiple allegations: incorrect medication administration, insufficient staffing, cigarette odor in resident rooms, and meal service issues. The medication error allegation involved a staff member who had not worked as a med tech for approximately three months. Staffing schedules and resident/staff statements indicated staffing levels had increased recently. The cigarette odor was linked to residents smoking outside designated areas, with corrective steps taken by the facility. Meal service allegations were disproven by menu review, resident interviews, and direct observation.

The investigation found the allegations regarding medication errors, staffing levels, and cigarette odor to be unsubstantiated, with conflicting information and no preponderance of evidence. The allegations about meal service quality, timing, and dietary needs were deemed unfounded, with observations confirming appropriate meal options, adherence to dietary restrictions, and accurate posted dining hours.

The complaint investigation addressed allegations that the administrator was not present for sufficient hours, residents were not receiving medically prescribed diets or nutritional meals, and facility staff was inadequate to meet residents' needs. All allegations were found to be unsubstantiated or unfounded based on observations, interviews, and documentation review.

The investigation found the allegations to be unsubstantiated or unfounded. The administrator was confirmed to be present for sufficient hours, residents reported no issues with prescribed diets or meals, and staffing levels were adequate despite a shortage of dining staff with caregivers filling in during meal times.

The applicant and administrator demonstrated understanding of licensing requirements, admission policies, staffing, health conditions, emergency preparedness, complaints reporting, and pre-licensing readiness during the COMP II interview process.

The applicant and administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and reporting.