198603189-6-1-2023-28-AS-FFIS-CVZM9Q-20230925092503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603189
Report Date: 06/01/2023
Date Signed: 06/01/2023 01:39:27 PM

Substantiated

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
05/31/2023 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20230531145412

FACILITY NAME:	MAISON DE FLEURS		FACILITY NUMBER:	198603189
ADMINISTRATOR:	PAGANOS, GEORGE		FACILITY TYPE:	740
ADDRESS:	4918 N SUNFLOWER AVE		TELEPHONE:	(714) 606-1854
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	6	CENSUS: 5	DATE:	06/01/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Staff#1, staff in charge		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not provide authorized representative with resident's records

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegation listed above. LPA met with staff#1at the facility, spoke with administrator assistant and licensee over the phone during the visit. LPA explained the purpose of today's visit to them.

The investigation consisted of the following: LPA interviewed staff from staff#1 to staff#3 and reviewed records. LPA obtained copies of resident roster, staff roster, document request, dated 05/18/23 (Electronic mail) with a Power of attorney.

In regard to allegation "staff did not provide authorized representative with resident's records," it was alleged that facility did not provide the requested document to resident#1’s attorney on a timely basis. LPA interviewed Administrator and staff. Staff interviews revealed resident#1 was a former resident residing at the facility from Aug 2021 to Sept 2021.
(-continued in LIC 9099 C-)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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 28-AS-20230531145412

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: 06/01/2023

NARRATIVE

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Per facility record reviews, an authorization/ power of attorney was provided to licensee along with the record request dated 05/18/23. Licensee had not provided the requested documents to authorized representative as of today, 06/01/23. Therefore, facility failed to provide resident’s records to the authorized representative within two (2) business day.

Based on LPA's observations, record reviews and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found SUBSTANTIATED.

Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D.

An exit interview was conducted with staff#1. A hard copy of this report and appeal right were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230531145412

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: 06/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/05/2023 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	(19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Licensee agreed to provide the requested resident records to authorized representative by POC due date.
	8 9 10 11 12 13 14	Per interviews conducted and record reviews, Licensee failed to provide resident#1’s records to resident#1’s authorized representative upon written request on 05/18/23, which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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