197803389-6-14-2023-11-AS-EMAZ-CV5RZW-20230828132838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803389
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:15:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/05/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20230605161242

FACILITY NAME:	ORANGE COMMUNITY CARE		FACILITY NUMBER:	197803389
ADMINISTRATOR:	SAAFIR, AHMED		FACILITY TYPE:	735
ADDRESS:	2103 ORANGE AVENUE		TELEPHONE:	(562) 599-0856
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90806
CAPACITY:	36	CENSUS: 24	DATE:	06/14/2023
		UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	ADMINISTRATOR AHMED SAAFIR		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident in care was seen infested with bedbugs and lice

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Orange Community Care facility on 06/14/2023 and was greeted by Administrator Ahmed Saafir (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

During this investigation, LPA Calderon interviewed A1, S1-S3 and interview C1-C6. These interviews were conducted on 06/14/2023. On 06/08/2023 LPA Calderon requested copies of the following: Staff and Client rosters, pest control reports for April and May 2023, incident report, needs and service plan, physician report, doctors report on C1. On 06/14/2023 LPA Calderon toured the common areas and bedrooms with A1

The investigation revealed the following:

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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 4

Control Number 11-AS-20230605161242

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ORANGE COMMUNITY CARE	FACILITY NUMBER: 197803389
	VISIT DATE: 06/14/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding Allegation #1: Client in care was seen infested with bedbugs and lice.

The alleged client in care was seen infested with bedbugs and lice. On 06/14/2023 LPA Calderon interviewed A1 for complaint. A1 relays that S1 called A1 cell phone to inform A1 that C1 was transported to the hospital due to health issues. A1 relays that S1 called 911 as C1 did not respond to verbal calls. A1 relays that C1 was seen by doctor on 05/05/2023 and there was no mention of bedbugs or lice. A1 relays that A1 spoke to C1 2 days prior to the incident and C1 did not have bedbugs or lice. A1 relays that A1 spoke to the hospital and was advised that C1 had a stroke and then 2 days later the social worker informed A1 that C1 had bedbugs and lice, which A1 does not believe C1 had bedbugs or lice but does not dispute the hospital diagnoses. On 06/14/2023 LPA Calderon interviewed S1 for complaint. S1 relays that S1 was serving clients dinner at 6pm and that S1 had just given C1 a cup of juice. S1 relays that S1 heard other clients yell out “C1 has passed out”. S1 relays that S1 left the kitchen and found C1 on the ground non-responsive. S1 checked to see if C1 was breathing and then called 911. S1 relays that S1 did not notice if C1 had bedbugs or lice but S1 does not think so. On 06/14/2023 LPA Calderon interviewed S2-S3 for complaint. Staff relays that there is no bedbugs or lice in the facility. Staff relay that they checked C1 room and bed for bedbugs or lice and found none. Staff relays that they change the clients bed sheets 2 times per week and clean the rooms daily and have found no bedbugs or lice. On 06/14/2023 LPA Calderon could not interview C1 as C1 is still in the hospital at this time. On 06/14/2023 LPA Calderon interviewed C2-C6 for complaint. C2 and C5 relay that they have never had bedbugs or lice in their room and have not seen any bedbugs or lice in the facility. C3 relays that C3 notice bedbugs in C3 room 2 weeks ago and C3 reported the bedbugs and staff cleaned C3 room and there were no issues going forward. C4 relays that C4 did not have bedbugs or lice in C4 room but did see other clients with red spots and scratching their heads. C4 does not know for sure if other clients had bedbugs or lice but C4 believes this is true. On 06/14/2023 LPA Calderon reviewed C1 facility file. LPA Calderon did not note any mention of bedbugs or lice associated to C1, A1 could not produce any pest control reports for 2023 due to A1 relays no issues with pests. LPA Calderon reviewed doctors report dated 05/05/2023 regarding C1 checkup. No mention of C1 having issues with bedbugs or lice. On 06/14/2023 LPA Calderon and A1 toured the facility. C6 walked up to LPA Calderon and walked LPA Calderon to room 1C, showed LPA Calderon a shirt that was covered with dead bedbugs. LPA Calderon did not note or find any moving bedbugs in the facility.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20230605161242

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ORANGE COMMUNITY CARE	FACILITY NUMBER: 197803389
	VISIT DATE: 06/14/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of “Client in care was seen infested with bedbugs and lice” is found to be SUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator Ahmed Saafir (A1).

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230605161242

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ORANGE COMMUNITY CARE	FACILITY NUMBER: 197803389
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/23/2023 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.his requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide LPA, per email, procedures for the elimination of bedbugs, from the facility, and conduct a staff training informing all staff at the facility of the procedures of the elimination plan of bedbugs in the facility by POC date of 06/23/2023
	8 9 10 11 12 13 14	Based on interview, observation, and record review the licensee failed to ensure that the facility is free of bedbugs, as reported to LPA on 06/14/23, per 3 of 6 clients interviewed informed LPA that the facility has bed bugs LPA checks identified rooms with bed bugs, 1C, which posed a potential health risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4