300603359-12-28-2021-22-AS-SSAS-CQ5UB7-20230321152553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300603359
Report Date: 12/28/2021
Date Signed: 12/28/2021 03:50:45 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
12/23/2021 and conducted by Evaluator Michelle Reed

COMPLAINT CONTROL NUMBER: 22-AS-20211223115748

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:	12/28/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Zenaida Deocampo		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
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8
9

Staff did not seek timely medical attention for resident
Resident received an injury due to lack of supervision

INVESTIGATION FINDINGS:

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5
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12
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Licensing Program Analyst Michelle Reed arrived at the facility to discuss the complaint allegation. Upon arrival, LPA met with Staff Allan Agis and Natividad Celestino. Licensee and Administrator Kristine Lenares was contacted via telephone and Licensee Zenaida DeOcampo arrived shortly after LPA. R1 was admitted into the facility on 6/15/16. Interviews were conducted and records were reviewed. R1 has Aphasia and is paralyzed. R1 uses a wheelchair for mobility. On 12/11/21 R1 was sitting on the back porch and attempted to roll down the back ramp of the facility. R1 bumped her right eye on the railing causing a bruise and a cut above her eyebrow. Staff administered first aid. On 12/19/21 R1 complained of pain in her side while family was visiting. Facility recommended family take R1 to the hospital due to the pain. R1 was admitted on 12/19/21 for pneumonia and returned to the facility 12/24/21.
Based upon interviews and a review of records the allegations are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that staff failed to provide supervision or seek timely medical treatment. An exit interview was conducted with Zenaida DeOcampo and a copy of this report was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

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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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
12/23/2021 and conducted by Evaluator Michelle Reed

COMPLAINT CONTROL NUMBER: 22-AS-20211223115748

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:	12/28/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Zenaida Deocampo		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not notify responsible representative regarding incident involving resident.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst Michelle Reed arrived at the facility to discuss the complaint allegation. Upon arrival, LPA met with Staff Allan Agis and Natividad Celestino. Licensee and Administrator Kristine Lenares was contacted via telephone and Licensee Zenaida DeOcampo arrived shortly after LPA. R1 was admitted into the facility on 6/15/16. Interviews were conducted and records were reviewed. R1 has Aphasia and is paralyzed. R1 uses a wheelchair for mobility. On 12/11/21 R1 was sitting on the back porch and attempted to roll down the back ramp of the facility. R1 bumped her right eye on the railing causing a bruise and a cut above her eyebrow. Staff administered first aid. Interviews were conducted and records were reviewed.
R1's responsible party was not immediately made aware of the incident and injury that occurred on 12/11/21 therefore the preponderance of evidence standard has been met and the above allegation is substantiated.
See attached LIC9099D for cited deficiency per California Code of Regulations, (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report and appeal rights were provided to Licensee Zenaida DeOcampo.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

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 3

Control Number 22-AS-20211223115748

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/29/2021 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements-Each licensee shall furnish to the licensing agency and the resident's responsible party a written report regarding any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to notify Licensing as well as the responsible parties immediately and in writing of any injuries that occur to residents at the facility. The LIC624 can be used for such reporting.
	8 9 10 11 12 13 14	R1 bumped her head on the handrail of the ramp outside the back patio causing an injury to her eye and eyebrow and the facility staff failed to notify her responsible party and Licensing of the injury. This poses a possible health and safety and personal rights risk to resident's 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.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC9099 (FAS) - (06/04)

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