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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002287
Report Date: 02/16/2024
Date Signed: 02/16/2024 11:46:01 AM

Substantiated


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
11/15/2023 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231115094434
FACILITY NAME:LORRAINE GUEST HOMEFACILITY NUMBER:
306002287
ADMINISTRATOR:TERESITA LOZANOFACILITY TYPE:
740
ADDRESS:5742 BELLE AVENUETELEPHONE:
(714) 828-6640
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:6CENSUS: 5DATE:
02/16/2024
UNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Maryjane Tan-StaffTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff allow resident to continue self-neglect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on 11/15/23. LPA was greeted and granted entry into the facility and met with Staff Maryjane Tan. LPA explained the reason for the visit. Administrator (AD) Teresita Lozano was notified by staff via telephone.

This agency has investigated the complaint alleging that staff allow resident to continue self-neglect. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: One of six individuals interviewed confirmed the allegation. During the investigation LPA reviewed documents including the Lorraine Guest Home Appraisal/Needs and Service Plan dated 09/07/21 for Resident 1 (R1). Per Appraisal/Needs and Service Plan the Socialization, Emotional, Mental, Physical/Health and Functioning Skills sections were left blank. Therefore, the facility failed to properly assess R1 prior to admission.
CONTINUED ON LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
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-20231115094434
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: LORRAINE GUEST HOME
FACILITY NUMBER: 306002287
VISIT DATE: 02/16/2024
NARRATIVE
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Records reviewed by LPA Ramirez included the Unusual Incident/Injury Report (UIIR) dated 09/15/23 for R1. Per UIIR R1 was observed disoriented to reality. Per UIIR dated 10/30/23 R1 was agitated, disoriented, confused, delusional and anxious. Per California Code of Regulation under Reappraisal 87463 (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. During the investigation LPA reviewed documents including the Physician Report (LIC602A) dated 07/25/22 for R1. Per Physician Report R1 has a diagnosis of Mild Cognitive Impairment and is Able to Manage Own Medications. During the course of the interviews, AD stated that recently the facility began managing R1’s medications. During interviews with R1’s family member it was reported that while moving R1’s belongings that she found opioids and disposed of them. Per R1’s family member she decided to move R1 because she needed a higher level of care.

Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: staff allow resident to continue self-neglect 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 staff Tan and a copy of this report along with the Appeal Rights were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20231115094434
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: LORRAINE GUEST HOME
FACILITY NUMBER: 306002287
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/19/2024
Section Cited
CCR
87457(c)(1)
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Pre-Admission Appraisal - General (c)Prior to admission a determination of the prospective resident's suitability for admission shall be completed...(1)The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition
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Licensee/Administrator agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.
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and an evaluation of social factors...This requirement was not met as evidence by: The facility did not complete a Pre-Admission Agreement prior to R1 being admitted to the facility. Therefore, the facility failed to properly assess R1 prior to admission. This poses an immediate risk to the Health and Safety of residents in care.
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC9099 (FAS) - (06/04)
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