306001749-12-8-2023-22-AS-SSAS-CYG2G7-20231212162237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001749
Report Date: 12/08/2023
Date Signed: 12/08/2023 02:17:15 PM

Unfounded

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
12/07/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231207142516

FACILITY NAME:	ARVILINH HOME CARE		FACILITY NUMBER:	306001749
ADMINISTRATOR:	ARVIN BUMANGLAG		FACILITY TYPE:	740
ADDRESS:	9351 MELBA DRIVE		TELEPHONE:	(714) 643-9077
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	6	CENSUS: 4	DATE:	12/08/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Arvin Bumanglag, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility retained residents with prohibited health conditions.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of investigating the allegation listed above. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Arvin Bumanglag was notified of the visit by telephone and arrived later to assist with the visit.

At the time of the visit, there are four residents in care at the facility. LPA requested, obtained and reviewed resident records for all individuals in care, including their hospice file when applicable. Three out of four residents are documented to receive hospice care at this time. Following the discharge of one resident with a gastrostomy tube recently, there is a single resident present at the facility with a similar condition. Resident is confirmed to be amongst the residents admitted under hospice.

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: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20231207142516

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: ARVILINH HOME CARE	FACILITY NUMBER: 306001749
	VISIT DATE: 12/08/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099
Regarding the allegation that Facility retained residents with prohibited health conditions, the following has been concluded:
Based on staff and resident interviews conducted, observation of the facility's physical plant and review of records conducted during the facility visit, resident R1 is indicated to have been admitted to the facility on June 2, 2023 with a gastrostomy tube in place to address nutrition needs resulting from the resident's condition.

Prior to being admitted to the facility, the resident was also admitted under hospice care on May 27, 2023. Licensee thus did not require the Department to issue an exception to Title 22 Regulations applying to prohibited health conditions. Resident is receiving adequate care and supervision from facility staff with the addition of the hospice staff based on the reviewed log of facility visits.

Therefore the allegation is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. The Department has investigated this complaint.

An exit interview was conducted and a copy of this report was 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: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC9099 (FAS) - (06/04)

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