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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603189
Report Date: 08/11/2023
Date Signed: 08/11/2023 01:18:58 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/16/2021 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210816151435
FACILITY NAME:MAISON DE FLEURSFACILITY NUMBER:
198603189
ADMINISTRATOR:PAGANOS, GEORGEFACILITY TYPE:
740
ADDRESS:4918 N SUNFLOWER AVETELEPHONE:
(714) 606-1854
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 6DATE:
08/11/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Biblia Ong TIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Resident sustained an unexplained injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted a subsequent complaint visit in response to the allegation(s) listed above. LPA met with Biblia Ong and explained the reason for the visit.

Regarding the allegation of lack of supervision, specifically that resident #1 sustained an unexplained injury while in care. The investigation was conducted by the department, and consisted of interviews with staff, residents, and review of resident #1 medical records. The investigation revealed that resident #1 experienced a fall at the facility on 8/8/21. Staff was present when resident #1 fell. Staff stated that resident #1 did not express pain, and was only observed to have a small scrape on the side of his head. Staff stated that resident #1 was assessed by facility staff, but was not assessed by a medical professional. On 8/15/21, resident #1's family member observed that resident #1 was unable to stand. Resident #1's family member asked staff if anything had happened to resident #1, and staff disclosed that resident #1 had fallen from his wheelchair on 8/8/21. Resident #1's family member took resident #1 to hospital on 8/15/21, and resident #1 was diagnosed with a hip fracture.

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, therefore the allegations are UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
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 28-AS-20210816151435
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MAISON DE FLEURS
FACILITY NUMBER: 198603189
VISIT DATE: 08/11/2023
NARRATIVE
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The investigation revealed that although resident #1 sustained an injury, it was not due to lack of supervision. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/16/2021 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210816151435

FACILITY NAME:MAISON DE FLEURSFACILITY NUMBER:
198603189
ADMINISTRATOR:PAGANOS, GEORGEFACILITY TYPE:
740
ADDRESS:4918 N SUNFLOWER AVETELEPHONE:
(714) 606-1854
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 6DATE:
08/11/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Biblia Ong TIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident in a timely manner
INVESTIGATION FINDINGS:
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Regarding the allegation that staff did not seek medical attention for resident #1 in a timely manner. The investigation was conducted by the department, and consisted of interviews with staff, residents, and review of resident #1 medical records. The investigation revealed that facility staff did not ensure that resident #1 was assessed by a medical professional after falling at the facility on 8/8/21. Resident #1's family member took resident #1 to hospital on 8/15/21, after learning of resident #1's fall. Resident #1 was diagnosed with a hip fracture on 8/15/21. Facility staff also failed to report the incident to resident #1's family member and to community care licensing as required.

Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited according to California Code of Regulations, Title 22.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20210816151435
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MAISON DE FLEURS
FACILITY NUMBER: 198603189
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
87211(a)(1)(B)
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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Administrator will conduct and in service training with facilty staff regarding reporting requirements. Administrator will provide proof of training to LPA by POC due date.
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(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met as evidenced by: facility staff failed to report that resident #1 to community care licensing, and failed to report to resident #1's family member.
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Type B
08/18/2023
Section Cited
CCR
87464(f)(6)
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Basic services shall at a minimum include:
Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services.
This requirement was not met as evidenced by : facility staff did not ensure that resident #1 was assessed by a medical professional after falling on 8/8/21.
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Administrator will conduct an in service training with facility staff regarding meeting the basic services of the residents. Administrator will provide proof of training to LPA by POC due date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4