306000639-11-21-2023-22-AS-AORZ-CXZW2C-20231128155406

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000639
Report Date: 11/21/2023
Date Signed: 11/21/2023 04:52:36 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
08/30/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230830133537

FACILITY NAME:	GRANNY'S PLACE III		FACILITY NUMBER:	306000639
ADMINISTRATOR:	MALACA, ROCHEL		FACILITY TYPE:	740
ADDRESS:	24695 DORIA AVENUE		TELEPHONE:	(949) 533-5938
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 0	DATE:	11/21/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Rochel Malaca, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Residents are not receiving adequate care and supervision

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the licensee's offices for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted by administrator Rochel Malaca after explaining the purpose of the visit and listing the allegations in question.

Following the filing of the present complaint on August 30, 2023, an initial complaint investigation visit was conducted on September 5, 2023. LPA accompanied by caregiving staff conducted a tour of the physical plant. A review of residents records for the three residents present at the time of the visit was additionally conducted. Staff interviews with the two caregivers on duty were also conducted. Three resident interviews were attempted or conducted during the visit.
A follow-up visit was held on October 23, 2023. Two staff interviews were conducted. LPA was also able to verify that the facility is currently vacant, as notified by facility management on October 3, 2023.
CONTINUED ON FORM LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

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 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
08/30/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230830133537

FACILITY NAME:	GRANNY'S PLACE III		FACILITY NUMBER:	306000639
ADMINISTRATOR:	MALACA, ROCHEL		FACILITY TYPE:	740
ADDRESS:	24695 DORIA AVENUE		TELEPHONE:	(949) 533-5938
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 0	DATE:	11/21/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Rochel Malaca, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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9

Facility staff is responding inappropriately to resident's requests for assistance

Facility staff is withholding food service

Facility staff is consuming intoxicants while on duty

INVESTIGATION FINDINGS:

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

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the licensee's office for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted by administrator Rochel Malaca after explaining the purpose of the visit and listing the allegations in question.

Following the filing of the present complaint on August 30, 2023, an initial complaint investigation visit was conducted on September 5, 2023. LPA accompanied by caregiving staff conducted a tour of the physical plant. A review of residents records for the three residents present at the time of the visit was additionally conducted. Staff interviews with the two caregivers on duty were also conducted. Three resident interviews were attempted or conducted during the visit.
A follow-up visit was held on October 23, 2023. Two staff interviews were conducted. LPA was also able to verify that the facility is currently vacant, as notified by facility management on October 3, 2023.
CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

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 7

Control Number 22-AS-20230830133537

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRANNY'S PLACE III	FACILITY NUMBER: 306000639
	VISIT DATE: 11/21/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099-A
Two collateral visits at licensed facilities where two of the three residents present upon the initial visit conduct have been relocated to upon closure of the facility under investigation were conducted on November 16, 2023, as well as additional witness interviews in person or via telephone.

Regarding the allegation that Facility staff is responding inappropriately to resident's requests for assistance, the following has been concluded: Based on interviews conducted, instances of individual behavior that could be perceived as disrespectful were mentioned, but no specific accounts of established inappropriate behavior could be confirmed as having occurred.

Regarding the allegation that Facility staff is withholding food service, the following has been concluded: Based on interviews conducted and records reviewed, it could not be established that staff had ever actively withheld the provision of food as a retribution or retaliation against residents in care, nor could it be completely assessed that no such instances ever happened.

Regarding the allegation that Facility staff is consuming intoxicants while on duty, the following has been concluded: One witness account stated the presence of alcohol at the facility, although it was not directly observed being consumed. Despite accounts of a specific staff member being volatile, no evidence of the staff member in question actually working while under the influence were provided. Besides one witness, all other witnesses deny having ever seen the presence of alcohol in the physical plant, while sometimes stating not having looked for it specifically.

The three allegations listed above are therefore Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
08/30/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230830133537

FACILITY NAME:	GRANNY'S PLACE III		FACILITY NUMBER:	306000639
ADMINISTRATOR:	MALACA, ROCHEL		FACILITY TYPE:	740
ADDRESS:	24695 DORIA AVENUE		TELEPHONE:	(949) 533-5938
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 0	DATE:	11/21/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Rochel Malaca, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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3
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5
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9

Admission agreements have not been updated following a change in ownership

INVESTIGATION FINDINGS:

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3
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5
6
7
8
9
10
11
12
13

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the licensee's office for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted by administrator Rochel Malaca after explaining the purpose of the visit and listing the allegations in question.

Following the finding of the present complaint on August 30, 2023, an initial complaint investigation visit was conducted on September 5, 2023. LPA accompanied by caregiving staff conducted a tour of the physical plant. A review of residents records for the three residents present at the time of the visit was aditionally conducted. Staff interviews with the two caregivers on duty were also conducted. Three resident interviews were attempted or conducted during the visit.
A follow-up visit was held on October 23, 2023. Two staff interviews were conducted. LPA was also able to verify that the facility is currently vacant, as notified by facility management on October 3, 2023.
CONTINUED ON FORM LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

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 7

Control Number 22-AS-20230830133537

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRANNY'S PLACE III	FACILITY NUMBER: 306000639
	VISIT DATE: 11/21/2023

NARRATIVE

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SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 22-AS-20230830133537

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRANNY'S PLACE III	FACILITY NUMBER: 306000639
	VISIT DATE: 11/21/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099
Two collateral visits at licensed facilities where two of the three residents present upon the initial visit conduct have been relocated to upon closure of the facility under investigation were conducted on November 16, 2023, as well as additional witness interviews in person or via telephone.

Regarding the allegation that Residents are not receiving adequate care and supervision, the following has been concluded: Based on interviews conducted, multiple instances of staff failing to address the care and supervision needs of residents in care were identified to have occurred. At least two separate witness accounts indicate inappropriate cell phone usage such as remaining on the phone as a resident in care requires assistance or providing assistance with showering and toileting while also conducting a conversation over speakerphone. Other instances of residents not receiving required assistance with meals were also evidenced. The occurrences were identified to be related to the policy in place regarding staff breaks, in spite of measures in place to ensure the continuity of staff presence throughout the day, most notably through rotating field supervisors that were not utilized during the incidents in question.

As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence has been met. A corresponding type B deficiency was cited on the attached form LIC9099-D.

An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 22-AS-20230830133537

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GRANNY'S PLACE III	FACILITY NUMBER: 306000639
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/22/2023 Section Cited HSC 1569.2(c)	1 2 3 4 5 6 7	"Care and supervision" means the facility assumes responsibility for (...) ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered". Based on interviews conducted, staff failed to provide (...)	1 2 3 4 5 6 7	The facility is currently not operating at this time. Upon resumption of services and admission of new residents, licensee states adequate staff training and coverage will be provided to address resident's needs.
	8 9 10 11 12 13 14	(...) necessary assistance to residents in care on multiple occasions. This constitute a potential risk to the health, safety and personal rights of the individuals 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) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 7