<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001093
Report Date: 03/02/2023
Date Signed: 03/02/2023 01:51:39 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
02/17/2023 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230217133353
FACILITY NAME:ROCHELLE MANORFACILITY NUMBER:
306001093
ADMINISTRATOR:ALFREDO RINGORFACILITY TYPE:
740
ADDRESS:12841 ADELLE STTELEPHONE:
(714) 537-3188
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:20CENSUS: 13DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Foster Ringor - AdministratorTIME COMPLETED:
02:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not meeting resident's needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to deliver the findings of the investigation into the above allegation. LPA Velazquez was allowed entry into the facility and met with Administrator Foster Ringor.

On today's visit LPA Velazquez conducted interviews with staff and looked in on Resident (R) #1 who was lying in their bed resting in their room and watching TV.
During the course of the investigation the following was revealed: LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also reviewed and obtained copies of facility, resident, and staff records. The records reviewed included R1's Client Development and Evaluation Report (CDER), Individual Program Plan (IPP), Physician's Report, Special Incident Report for an incident dated February 17, 2023 documenting redness and skin breakdown, Advanced Center for Urology records, Admission Agreement, Resident Appraisal, Preplacement Appraisal Information, Medication Sheet, Centrally Stored Medication and Destruction
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 03/02/2023
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 3
Control Number 22-AS-20230217133353
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: ROCHELLE MANOR
FACILITY NUMBER: 306001093
VISIT DATE: 03/02/2023
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
Record, and Rochelle Manor Facility Reports. During the interviews conducted and email communication between Staff (S) #1 and LPA Velazquez, S1 confirmed that R1 was sent to the Day Program without R1's Hoyer Lift Sling on two different occasions. S1 also confirmed facility staff failed to include R1's disposable briefs in R1's backpack on at least one occasion when R1 was sent to their Day Program. Six of seven individuals interviewed provided conflicting statements and could not corroborate the allegation. S1 further stated they are working with the Regional Center Orange County Service Coordinator and Quality Assurance Coordinator to ascertain if R1 requires a higher level of care than what can be provided at this facility.


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 allegation: Facility is not meeting resident's needs is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator Foster Ringor and a copy of this report along with the Appeal Rights, LIC 811s, and LIC 9098 were provided at the time of this visit.

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

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

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20230217133353
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: ROCHELLE MANOR
FACILITY NUMBER: 306001093
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2023
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
Basic Services. Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as
1
2
3
4
5
6
7
Licensee to ensure all residents' needs are met at all times. Licensee to conduct an in-service staff training regarding this regulation by 3/4/2023. Licensee to provide the name of the instructor, their qualifications, and
8
9
10
11
12
13
14
evidenced by: based on resident record review & interviews conducted the licensee failed to provide R1's sling and briefs as needed. This poses an immediate risk to the health and safety of residents in care.
8
9
10
11
12
13
14
submit written proof of the staff training to LPA by POC due date. The licensee to provide LPA a written statement indicating they have read this section of Title 22 regulation and how exactly they intend to adhere to it by POC due date.
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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3