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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000106
Report Date: 08/27/2021
Date Signed: 08/27/2021 01:26:16 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, 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
08/26/2021 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210826155942
FACILITY NAME:PROMISES GUEST VILLAGEFACILITY NUMBER:
306000106
ADMINISTRATOR:DANTE ENCARNACIONFACILITY TYPE:
735
ADDRESS:1315-1321 ANAHEIM BLVD.TELEPHONE:
(714) 774-1544
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:40CENSUS: 40DATE:
08/27/2021
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Adinistrator, Dante EncarnacionTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Facility is strapping exit doors
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to conduct a complaint investigation. LPA identified themselves, discussed purpose of the visit and allegations with Administrator Dante Encarnacion.

During visit LPA toured facility lobby, dining room, kitchen, med tech station,client rooms,restrooms and outside patio areas. LPA conducted interviews. Clients were observed relaxing in outside patios, bedrooms, and lobby areas. Staff and clients were observed wearing masks.LPA requested pertinent documents.

During time of visit Facility exits/entrances were not strapped down however the investigation revealed that based off interviews 4 out of 4 staff admitted to two of the exit/entrances were previously strapped due to covid percautions providing evidence that the above allegation facility is strapping exit doors was true. The Agency has investigated the complaint and the preponderance of evidence standard has been met
CONTINUED ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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 3
Control Number 22-AS-20210826155942
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: PROMISES GUEST VILLAGE
FACILITY NUMBER: 306000106
VISIT DATE: 08/27/2021
NARRATIVE
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 therefore the above allegation is found to be SUBSTANTIATED, California Code of Regulations, Title 22, Division 6, Chapter 3 are being cited on the attached LIC 9099 D.

An exit interview was conducted with Administrator Dante Encarnacion and A copy of report was provided to facility along with appeal rights. A hard copy will be kept on file.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20210826155942
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: PROMISES GUEST VILLAGE
FACILITY NUMBER: 306000106
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2021
Section Cited
CCR
82087(c)
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Physical Environment- Buildings and Grounds
All outdoor and indoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard shall be kept free of obstruction.

This requirement is not being met as evidenced by:
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Administrators plan of correction is to retrain staff on fire drills on building and grounds requirements.

Administrator to write a self declaration for staff attesting to these trainings due by 8/28/21.
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4 out of 4 staff admitted to exit ways being strapped down. This poses an immediate Health and Safety Risk to residents in care.
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Administrator needs to provide proof of training and signature of Staff declaration due 1 week by 9/3/2021
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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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3