306001851-2-2-2023-22-AS-SSAS-CNUPJY-20230208102215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001851
Report Date: 02/02/2023
Date Signed: 02/02/2023 04:05:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
11/17/2022 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221117100411

FACILITY NAME:	KATHRYN JANE RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	306001851
ADMINISTRATOR:	ALFONSO/EDILMA AVENDANO		FACILITY TYPE:	740
ADDRESS:	26861 VIA GRANDE		TELEPHONE:	(949) 632-3762
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 3	DATE:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Alfonso Avendano, administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Personal Rights Violation

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 delivering findings into the investigation of the allegation listed above. LPA was greeted and granted entry by caregiving staff after explaining the purpose of the visit and being screened for COVID-19 symptoms. Administrator Alfonso Avendano was notified by telephone and arrived later to assist with the visit.

Complaint investigation visits were previously conducted on November 17, 2022 and November 21, 2022. Two (2) staff were interviewed in addition to the administrator and five (5) witness interviews were conducted. A review of records including hospice records, physician report and facility check-in forms were also requested and reviewed.

LPA toured the physical plant with facility staff during the initial visit and was able to observe various other relatives visit with resident R1.
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: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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-20221117100411

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: KATHRYN JANE RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 306001851
	VISIT DATE: 02/02/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099

After an initial disagreement in regard to the requirements applicable to visitors staying at the facility around the clock, it was later observed that a compromise was reached regarding access to resident R1's bedroom and visiting hours as resident was transitioning. Multiple visits by the chaplain and hospice social worker have additionally been documented in records reviewed by LPA.

Although the allegation that the Resident's personal rights have been violated may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

An exit interview was conducted and a copy of this report was provided and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

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