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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300606285
Report Date: 02/16/2023
Date Signed: 02/16/2023 10:26:09 AM

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
01/19/2022 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220119133037
FACILITY NAME:CENTURY GUEST HOME, THEFACILITY NUMBER:
300606285
ADMINISTRATOR:LIEZL DEOCAMPOFACILITY TYPE:
740
ADDRESS:14332 HOLT AVETELEPHONE:
(714) 544-7909
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 4DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Liezl DeocampoTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff caused bruising to resident
Staff did not assist resident with incontinence needs
Staff did not report bruising to resident’s authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michelle Reed met with Administrator Liezl Campos to discuss the complaint findings for the above allegations. The investigation was investigated by the Department and consisted of interviews with Administrator, staff and witnesses as well as documentation from the facility file. The following was determined:

Resident #1(R1) was admitted into the facility on September 27, 2021. R1 has Cognitive Impairment and needs assistance with medication and all Activities of Daily Living. R1 was often visited by family and due to conflict was appointed a Conservator for finances.

Interviews and a review of records did not disclose any mistreatment or physical abuse from staff. R1 bruises easily and has hit her arms on the night stand and the rails of her bed. R1 stated that staff care for her toileting needs and she gets her showers. Staff also conduct and document full body checks for R1 when she is bathed. R1 is also receiving hospice services and hospice visits twice a week. R1’s responsible party
listed on her Identification and Emergency Information form was notified of R1’s bruising.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
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 2
Control Number 22-AS-20220119133037
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: CENTURY GUEST HOME, THE
FACILITY NUMBER: 300606285
VISIT DATE: 02/16/2023
NARRATIVE
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Based upon interviews and a review of R1's records, these 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 the alleged violations occurred.

An exit interview was conducted with Liezl Campos and a copy of this report was provided



SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2