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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002287
Report Date: 11/21/2023
Date Signed: 11/21/2023 04:05:32 PM

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: 4DATE:
11/21/2023
UNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Adoracion Torres-CaregiverTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Resident's medications were mismanaged while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Caregiver Adoracion Torres. LPA explained the reason for the visit. Administrator (AD) Teresita Lozano arrived shortly after.

On today’s visit LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: One of five individuals interviewed corroborated the allegation. During interviews conducted with Resident 1 (R1), R1 reported that the caregivers manage their medications. During interviews conducted with staff, Staff 1 (S1) reported that the AD prepares the medications a day in advance and places it in individual plastic containers. During the investigation LPA reviewed documents including the Physician Report (LIC602A) dated 08/26/2019 for R2 and 12/21/2020 for R3.
CONTINUED ON LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
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 4
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: 11/21/2023
NARRATIVE
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Per Physician Report R2 and R3 are not Able to Administer Own Prescription Medications. At 12:58 PM LPA toured the facility and observed ready to dispense medication in small labeled plastic pill organizers.

Based on the observations, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Resident's medications were mismanaged while in care 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 AD Lozano and a copy of this report and the Appeal Rights were provided at the time of this visit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 11/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2023
Section Cited
CCR
87465(h)(5)
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Incidental Medical and Dental Care: The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as
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Per Licensee/Administrator an in-house training on how to properly manage centrally stored medications will be conducted. Licensee to email POC to LPA by POC due date.
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evidence by: Per interviews conducted and LPA's observations, the Administrator prepares the residents' medication a day in advance and places it in small labeled plastic pill organizers. This poses an immediate risk to resident’s health and safety.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
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