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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000523
Report Date: 07/21/2022
Date Signed: 09/15/2022 02:42:28 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
06/15/2022 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220615101923
FACILITY NAME:ANAHEIM GUEST HOMEFACILITY NUMBER:
306000523
ADMINISTRATOR:EVELYN ENCARNACIONFACILITY TYPE:
735
ADDRESS:127 W. HILL PLTELEPHONE:
(714) 776-3075
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:40CENSUS: 39DATE:
07/21/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Evelyn EncarnacionTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Facility lacks care and supervision.

Facility unable to meet clients needs resulting in multiple falls.
INVESTIGATION FINDINGS:
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 This is an amended report.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Administrator (AD) Evelyn Encarnacion and Assistant Administrator (AAD) Jerel Encarnacion. LPA was taken on a guided tour of the indoors and outdoors of the facility by AD.

Complaint alleges facility lacks care and supervision and facility is unable to meet Client 1’s (C1) needs resulting in multiple falls.

Interviews were conducted with Administrator (AD) Evelyn Encarnacion, staff, and Client 2 (C2). LPA could not interview C1, as C1 was hospitalized and in the Intensive Care Unit (ICU). (Cont. on LIC9099-C)

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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 3
Control Number 22-AS-20220615101923
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: ANAHEIM GUEST HOME
FACILITY NUMBER: 306000523
VISIT DATE: 07/21/2022
NARRATIVE
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During interviews facility staff admitted that C1 has fallen a total of three times in the last six months beginning January 2022 and none of these instances were witnessed by staff. C2 stated they did not see C1 fall but heard a “thud” and observed C1 bleeding on the right side of their head. C2 then alerted staff, who took “about 5 minutes to go check” on C1. LPA reviewed the Needs and Services Plan (LIC625) for C1 dated 3/02/2022, which states the facility “feels” C1 needs more supervision and a higher level of care. The facility, however, did not provide C1 with more supervision or assistance in obtaining a higher level of care. Per disclosures made during interviews, and records obtained by LPA, it was determined that facility lacks care and supervision and facility is unable to meet client’s needs resulting in multiple falls. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated California Code of Regulations, Title 22, 85075.4(b) and 85078(a)(1).

An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20220615101923
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: ANAHEIM GUEST HOME
FACILITY NUMBER: 306000523
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2022
Section Cited
CCR
85075.4(b)
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Observation of the Client
The licensee shall provide assistance when observation reveals needs which might require a change in the existing level of service, or possible discharge or transfer to another type of facility.
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Licensee states C1 is currently in a Skilled Nursing Facility (SNF) following an additional fall. Licensee will work with SNF to ensure placement and will provide LPA with a copy of C1's new assessment/care and services plan provided by SNF via email by 7/22/22.
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The requirement was not met as evidence by; during the course of the investigation, LPA determined that Needs and Services Plan (LIC625) dated 3/02/2022, states C1 “needs a higher level of care.” Per LIC625, facility is unable to meet C1’s needs, resulting in multiple falls, which poses an immediate health and safety risk.
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Type A
07/22/2022
Section Cited
CCR
85078(a)(1)
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Responsibility for Providing Care and Supervision
The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.

The requirement was not met as evidence by; during the course of the investigation LPA
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Licensee states C1 is currently in a Skilled Nursing Facility (SNF) following an additional fall. Licensee will work with SNF to ensure placement and will provide LPA with a copy of C1's new assessment/care and services plan provided by SNF via email by 7/22/22.
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determined that Needs and Services Plan (LIC625) for C1 dated 3/02/2022 states, “we feel that he needs more supervision and a higher level of care.” Licensee did not provide C1 additional supervision or assistance in obtaining a higher level of care as identified in LIC625, which poses an immediate health and safety risk.
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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: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3