300603359-5-5-2022-22-AS-AORZ-CEZPWY-20220602114127

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300603359
Report Date: 05/05/2022
Date Signed: 05/05/2022 12:53:08 PM

Unfounded

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
04/26/2022 and conducted by Evaluator Andrea Mendivil

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220426165239

FACILITY NAME:	GOLDEN YEARS GUEST HOME THE		FACILITY NUMBER:	300603359
ADMINISTRATOR:	KRISTINE R LINARES		FACILITY TYPE:	740
ADDRESS:	14752 HOLT AVE		TELEPHONE:	(714) 731-6385
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	15	CENSUS: 11	DATE:	05/05/2022
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Zenaida DeOcampo- Licensee and Kristine Linares- Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's medical records are not up to date
Facility failed to provide appropriate care and supervision

INVESTIGATION FINDINGS:

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

On this day, Licensing Program Analyst (LPA) Andrea Mendivil and Licensing Program Manager (LPM) Alisa Oritz made an unannounced visit to conduct a complaint investigation. LPA and LPM identified themselves and were met with Zenaida DeOcampo , Licensee and Kristine Linares, Administrator. LPA and LPM spoke to Zenaida DeOcampo and Kristine Linares and discussed the above allegations.

It was alleged that resident's medical records are not up to date and facility failed to provide appropriate care and supervision. During the course of the investigation, LPA reviewed pertinent documents such as resident's medication records, hospital discharge paperwork, resident's needs and service plan dated 06/8/2021 and resident's physician report dated 03/08/2021. The Department has investigated the complaint and has determined as follows.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

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 2

Control Number 22-AS-20220426165239

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: GOLDEN YEARS GUEST HOME THE	FACILITY NUMBER: 300603359
	VISIT DATE: 05/05/2022

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

Per paperwork reviewed Resident 1 (R1) was admitted to facility on 06/15/2016. Physician report reviewed dated 03/08/2021 notes that R1 has no history of substance abuse problems, use of alcohol or motor impairment. The physician report further notes that R1 is able to communicate their needs but is not able to administer own medications.

It was reported that on 4/23/2022 R1 was visited by a family member who arrived to facility and provided R1 with alcoholic beverages. Prior to visit R1 had been hospitalized and discharged with a change in medication unknown to visitor. After discovering that R1 had been provided alcoholic beverage by family member facility licensee notified responsible party and advised visitor not to provide alcoholic beverages to R1 due to fear of mixture of medications and alcohol. A review of R1 medication log notes that R1's medication was given consistently as prescribed, during this period facility staff cross reported to R1's PACE social worker and monitored R1 accordingly.

During an interview with facility Administrator Kristine Linares, Administrator acknowledged the facility house rules do not exclude alcohol from the premises. Interviews conducted with 2 of 2 staff present at the time of the incident report that R1's drinking is not a continuous habit and do not have concerns about meeting R1's needs. During the visit LPA observed R1 who appeared well groomed and dressed.During interview emotions varied and fluctuated between refusing to be interviewed and wanting to be interviewed.

Therefore based on the preponderance of evidence gathered, interviews conducted, records reviewed and observations made the allegations resident's medical records are not up to date and facility failed to provide appropriate care and supervision are determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint and an exit interview was conducted with Zenaida DeOcampo Licensee and a copy of this report and LIC 811 was provided at the time of exit..

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2