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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001749
Report Date: 12/27/2022
Date Signed: 12/27/2022 11:13:00 AM

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
12/16/2022 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221216144132
FACILITY NAME:ARVILINH HOME CAREFACILITY NUMBER:
306001749
ADMINISTRATOR:ARVIN BUMANGLAGFACILITY TYPE:
740
ADDRESS:9351 MELBA DRIVETELEPHONE:
(714) 643-9077
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 6DATE:
12/27/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Arvin BumanglagTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff retained a resident with a prohibited health condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to this facility to deliver findings on complaint 22-AS-20221216144132. LPA Haley was granted entry by staff explained the reason for the visit.
Regarding the allegation: Staff retained a resident with a prohibited health condition

The initial complaint visit was conducted December 20, 2022. Interviews with the licensee, staff, and document review revealed the following:

Resident 1 (R1) was admitted to the facility December 10, 2022. During interviews it was revealed that R1 was admitted to the facility with a prohibited health condition (G-Tube). Furthermore, LPA Haley was informed during the interview process that the facility did not request an exception, did not notify the Regional Office or request an exception before admitting R1. LPA Haley also received a copy of R1’s LIC 602A that list the G-Tube under secondary diagnosis.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
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-20221216144132
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: ARVILINH HOME CARE
FACILITY NUMBER: 306001749
VISIT DATE: 12/27/2022
NARRATIVE
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Based on the evidence gathered, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1.

An exit interview was conducted and a copy of this report, LIC 9099D, and appeal rights were provided to Administrator Arvin Bumanglang.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20221216144132
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: ARVILINH HOME CARE
FACILITY NUMBER: 306001749
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/27/2022
Section Cited
CCR
87615(a)(2)
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87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly. (2) Gastrostomy tubes.
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Licensee agrees to notify the regional office and request an exception before accepting a resident with any prohibited health condition.
Licensee agrees to submit the required documentation and apply for an exception for the current resident with a G Tube by 12:00 noon Friday (12.30.22).
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This requirement is not being met as evidenced by: Licensee admitted a resident with a prohibited health condition (G Tube). The licensee did not notify the regional office or request an exception before admitting the resident.
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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.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3