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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000106
Report Date: 02/03/2023
Date Signed: 02/03/2023 12:09:28 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
05/09/2022 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220509160859
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: 38DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Rizza Engreso - Office Staff
Dante Encarnacion - Administrator		TIME COMPLETED:
12:25 PM
ALLEGATION(S):
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9
Medication was accessible to clients
Lack of qualified staff
INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings of the investigation into the above allegations. LPA Velazquez was allowed entry into the facility and initially met with Office Staff (OS) Maria Rizza Engreso and explained the purpose of the visit. Administrator Dante Encarnacion arrived later to assist LPA with the visit.

On today's visit LPA Velazquez requested and obtained copies of facility, client and staff records. LPA Velazquez also conducted an interview with OS Engreso. LPA along with OS conducted a medication review for 6 clients. Regarding the allegation: Medication was accessible to clients the investigation revealed the following: LPA Velazquez conducted interviews with the complainant, clients, and staff. LPA Velazquez also obtained and reviewed facility, client, and staff records. Records reviewed included Admission Agreements, House Rules, Physician’s Reports, Preplacement Appraisal Information, Appraisal Needs and Services Plans, Medication Administration Records (MARs), Centrally Stored Medication and Destruction Records
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
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 5
Control Number 22-AS-20220509160859
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: 02/03/2023
NARRATIVE
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(CSMDRs), and staff training records. During the initial complaint visit dated May 10, 2022 while touring the physical plant, LPA Patricia Velazquez along with Mark Shugarman, LMFT of the County of Orange Health Care Agency observed various unlocked client medications stored in plastic carts and many other client medications stored in plastic bags and placed in a storage room next to the kitchen. LPA Velazquez and LMFT Shugarman observed a client walk through the kitchen where apparently clients are not allowed to do so. The client medications were easily accessible to clients as they were not properly secured and locked. Seven of seven individuals interviewed provided conflicting statements and could not corroborate the allegations. At 9:57 AM today LPA Velazquez and OS Engreso conducted a review of medications for 6 clients with the medication cart located in the kitchen. Upon entering the kitchen LPA and OS observed 3 large unlocked kitchen cabinets containing client medications that were easily accessible to clients. LPA and OS also observed a small unlocked refrigerator located on top of a kitchen counter containing client medications. LPA and OS also observed a bag located on a chair in the kitchen that contained several client medications. During the medication review LPA and OS observed a client enter the kitchen and able to easily access all of the unlocked medication. All of the medications reviewed throughout the investigation contained labels with the name of the name of the dispensing pharmacy, name of the medication with dosage instructions and the client's name along with additional information.

Regarding the allegation Lack of qualified staff the investigation revealed the following: LPA Velazquez conducted interviews with the complainant, clients, and staff. LPA Velazquez also obtained and reviewed facility, client, and staff records. Seven of seven individuals interviewed provided conflicting statements and could not corroborate the allegation. The staff record review did not contain staff training documentation pursuant to statute and regulation which Administrator Encarnacion and OS Engreso confirmed. Administrator Encarnacion also confirmed the facility staff did not have training pursuant to statute and regulation

Based on LPA's observations, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Medication was accessible to clients and Lack of qualified staff are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 is being cited on the attached LIC 9099D.



An exit interview was conducted with Administrator Dante Encarnacion and Office Staff Maria Rizza Engreso and a copy of this report along with the appeal rights, and LIC 9098 were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20220509160859
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: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2023
Section Cited
CCR
80075(k)(1)
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Health Related Services. The following requirements shall apply to medications which are centrally stored: Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the
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Licensee to ensure all client medication is locked and inaccessible to clients at all times and submit written proof to LPA by POC due date.
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 supervision of the centrally stored medication. This requirement is not met as evidenced by: based on observation & Interview Licensee did not properly secure clients medications. This poses an immediate risk to the health & safety of clients in care.
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Type B
02/10/2023
Section Cited
CCR
80065(f)(1-6)
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Personnel Requirements. All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
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Licensee to ensure all staff are properly trained pursuant to statute and regulation and submit written proof to LPA by POC due date.
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This requirement is not met as evidenced by: based on observation & interview the Licensee failed to provide staff with adequate training pursuant to statute and regulation. This poses a potential risk to the health & safety of clients in care.
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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: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
05/09/2022 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220509160859

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: 38DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Rizza Engreso - Office Staff
Dante Encarnacion - Administrator		TIME COMPLETED:
12:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medication not labeled
Lack of staff to meet clients' needs
Lack of care and supervision including drug use in the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings of the investigation into the above allegations. LPA Velazquez was allowed entry into the facility and initially met with Office Staff (OS) Maria Rizza Engreso and explained the purpose of the visit. Administrator Dante Encarnacion arrived later to assist LPA with the visit.

On today's visit LPA Velazquez requested and obtained copies of facility, client and staff records. LPA Velazquez also conducted an interview with OS Engreso. Regarding the allegations: Medication not labeled, Lack of staff to meet clients' needs, and Lack of care and supervision including drug use in the facility the investigation revealed the following. LPA Velazquez conducted interviews with the complainant, clients, and staff. LPA Velazquez also obtained and reviewed facility, client, and staff records. Records reviewed included Admission Agreements, House Rules, Physician’s Reports, Preplacement Appraisal Information, Appraisal Needs and Services Plans, Medication Administration Records (MARs), Centrally Stored Medication and Destruction Records
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20220509160859
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: 02/03/2023
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
(CSMDRs), and staff training records. During the initial complaint visit dated May 10, 2022 while touring the physical plant, LPA Patricia Velazquez along with Mark Shugarman, LMFT of the County of Orange Health Care Agency observed various unlocked client medications stored in plastic carts and many other client medications stored in plastic bags and placed in a storage room next to the kitchen. LPA Velazquez and LMFT Shugarman observed a client walk through the kitchen where apparently clients are not allowed to do so. The client medications were easily accessible to clients as they were not properly secured and locked. Seven of seven individuals interviewed provided conflicting statements and could not corroborate the allegations. At 9:57 AM today LPA Velazquez and OS Engreso conducted a review of medications for 6 clients with the medication cart located in the kitchen. Upon entering the kitchen LPA and OS observed 3 large unlocked kitchen cabinets containing client medications that were easily accessible to clients. LPA and OS also observed a small unlocked refrigerator located on top of a kitchen counter containing client medications. LPA and OS also observed a bag located on a chair in the kitchen that contained several client medications. During the medication review LPA and OS observed a client enter the kitchen and able to easily access all of the unlocked medication. All of the medications reviewed throughout the investigation contained labels with the name of the dispensing pharmacy, name of the medication with dosage instructions and the client's name along with additional information. Administrator Encarnacion also informed LPA Velazquez that he has had a high turnover of staff. Throughout the investigation LPA Velazquez and Mark Shugarman, LMFT did not observe client drug use at the facility.

Based on the observations made, interviews which were conducted and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: Medication not labeled, Lack of staff to meet clients' needs, and Lack of care and supervision including drug use in the facility are deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Dante Encarnacion and Office Staff Maria Rizza Engreso and a copy of this report was provided at the time of this visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5