306002286-1-11-2023-22-AS-AORZ-CN9P96-20230120100638

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002286
Report Date: 01/11/2023
Date Signed: 01/11/2023 02:52:43 PM

Unfounded

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
10/15/2020 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201015123210

FACILITY NAME:	R & R CARE, INC.		FACILITY NUMBER:	306002286
ADMINISTRATOR:	ROMAN MATAGA		FACILITY TYPE:	740
ADDRESS:	14952 BURNHAM CIRCLE		TELEPHONE:	(949) 651-1830
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY:	6	CENSUS: 6	DATE:	01/11/2023
		UNANNOUNCED	TIME BEGAN:	01:09 PM
MET WITH:	Roman Mataga - Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff unlawfully evicted resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings of the investigation into the above allegation. LPA Velazquez was allowed entry into the facility by Caregiver Benedick Santos and explained the purpose of the visit. Administrator (ADMIN) Roman Mataga arrived shortly after LPA's arrival.

On today’s visit LPA Velazquez conducted interviews with staff. LPA Velazquez also reviewed and obtained copies of facility records and requested a copy of Resident (R) #1's records. Per ADMIN Mataga the facility does not have a file for R1 as ADMIN stated R1 was never formally admitted into the facility. On July 1, 2020 R1 arrived at R & R Care, Inc via ambulance after being discharged from South Coast Global Medical Center but was not accepted into the facility by ADMIN Mataga. ADMIN Mataga stated he could not accept the resident because R1 required Durable Medical Equipment (DME) such as a CPAP machine and Oxygen and the hospice agency had not delivered the DME to the facility prior to the arrival of R1. ADMIN Mataga indicated

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

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-20201015123210

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: R & R CARE, INC.	FACILITY NUMBER: 306002286
	VISIT DATE: 01/11/2023

NARRATIVE

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he informed the ambulance driver that the required DME had not arrived and ADMIN Mataga could not accept the resident and properly provide the care R1 required without the aforementioned DME being present. Per ADMIN the ambulance driver then indicated they would transport R1 back to South Coast Global Medical where R1 had been discharged from. R1 was subsequently released from South Coast Global Medical Center on July 2, 2020 to Whispering Oaks - Waverly with facility number 306003850 where R1 passed away on the morning of July 3, 2020. The individuals interviewed confirmed a written Admission Agreement was never executed between the facility and the family of R1. The family of R1 and ADMIN Mataga also confirmed that no preadmission fee or first month's fees were ever paid to the facility.

This agency has investigated the complaint and based on the above findings the following allegation: Staff unlawfully evicted resident while in care is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Administrator Roman Mataga and a copy of this report along with the LIC 811 was provided at the time of this visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

LIC9099 (FAS) - (06/04)

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