300603257-5-10-2023-22-AS-SSAS-CSC2P2-20230530173334

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300603257
Report Date: 05/10/2023
Date Signed: 05/10/2023 05:11:20 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/06/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230406093522

FACILITY NAME:	REGENTS POINT		FACILITY NUMBER:	300603257
ADMINISTRATOR:	FORNEY, MELINDA M		FACILITY TYPE:	741
ADDRESS:	19191 HARVARD AVENUE		TELEPHONE:	(949) 854-9500
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	399	CENSUS: 256	DATE:	05/10/2023
		UNANNOUNCED	TIME BEGAN:	03:01 PM
MET WITH:	Health and Wellness Director-Ashley Croslin		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Lack of staffing to meet the resident's needs.

Facility is misplacing resident's laundry.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver the findings for the complaint received on 4/6/23. LPA was greeted by front desk staff who notified Health and Wellness Director (HWD) Ashley Croslin about visit.

It was alleged that there is a lack of staffing to meet the resident's needs. LPA conducted a total of 11 interviews, of which 7 of the interviews conducted with residents, did not corroborate with the allegation by stating that facility had “enough” staff, “staff are really good” and “if I need anything, they respond very fast”. LPA conducted record reviews of the staff schedule and found that the facility ensures that there is adequate staffing in the clinical and maintenance department at all times, and that if coverage is needed, management will assist.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/06/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230406093522

FACILITY NAME:	REGENTS POINT		FACILITY NUMBER:	300603257
ADMINISTRATOR:	FORNEY, MELINDA M		FACILITY TYPE:	741
ADDRESS:	19191 HARVARD AVENUE		TELEPHONE:	(949) 854-9500
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	399	CENSUS:	DATE:	05/10/2023
		UNANNOUNCED	TIME BEGAN:	03:01 PM
MET WITH:	Health and Wellness Director-Ashley Croslin		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility is not being cleaned and disinfected.
Resident's medical devices are uncleaned and unsanitary.
Facility is not following Infection Control Requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver the findings for the complaint received on 4/6/23. LPA was greeted by front desk staff who notified health and Wellness director (HWD) Ashley Croslin about visit.

It was alleged that facility is not being cleaned and disinfected. Out of the 11 interviews conducted, all 11 interviews did not corroborate with the allegation, by stating that staff are “always cleaning”, and that “staff do a good job”. During LPA’s visit on 4/13/23, LPA conducted a tour of the facility and observed staff cleaning the rooms of residents. LPA also conducted a tour of the facility supply room and observed multiple disinfectant and cleaning supplies. LPA reviewed the staff schedule, maintenance and cleaning duties, and observed that on each shift, there is a staff member who is given the task to clean, in addition to the maintenance staff.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20230406093522

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: REGENTS POINT	FACILITY NUMBER: 300603257
	VISIT DATE: 05/10/2023

NARRATIVE

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It was alleged that resident's medical devices are uncleaned and unsanitary. Out of the 11 interviews conducted, 11 of the interviews did not corroborate with the allegation by stating that staff assist with, or offer to clean resident’s medical devices, if it is observed to be dirty or unsanitary. During the visit conducted on 4/13/23, LPA conducted tours of resident rooms, and common resident areas, and observed that the residents had medical devices that were clean.

It was alleged that facility is not following Infection Control Requirements. Out of the 11 interviews conducted, 11 interviews did not corroborate with the allegation by stating that since COVID-19, the facility has implemented Infection Control Requirements, and “still follows” the guidelines for cleaning, sanitization and disinfecting. 4 interviews also added that Infection Control is now a “normal thing” and “is exercised for good measure”. During LPA’s visit on 4/13/23, it was observed that the facility has Infection Control posters posted in the hallways, of which 7 of the interviews stated it serves as “good reminders”. LPA reviewed the facility binder of the monthly Infection Control Requirement trainings and invoices, and it was observed that the facility conducts monthly meetings to review Infection Control practices with all staff.

Based on observations and review of documents obtained, we have found that the allegations indicated were UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted an a copy of this report was provided and explained to HWD Croslin.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 22-AS-20230406093522

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: REGENTS POINT	FACILITY NUMBER: 300603257
	VISIT DATE: 05/10/2023

NARRATIVE

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It was alleged that facility is misplacing resident's laundry. Out of the 11 interviews conducted, 4 stated that there were no concerns regarding laundry misplacement, 5 interviews were unable to provide further information regarding this allegation, and in 2 of the interviews, it was reported that if there is a staff member on duty who is new, or is not yet familiar with residents, then another staff member will assist in locating the resident and return their belongings. LPA reviewed the laundry and staff schedule.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegations indicated may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED.

An exit interview was conducted an a copy of this report was provided and explained to HWD Croslin.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4