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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002855
Report Date: 05/16/2023
Date Signed: 05/16/2023 11:59:39 AM

Substantiated


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
05/10/2023 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230510110552
FACILITY NAME:LANEROSE HOMEFACILITY NUMBER:
306002855
ADMINISTRATOR:SUSAN A. BAGUEFACILITY TYPE:
735
ADDRESS:1238 S. WESTERN AVENUETELEPHONE:
(714) 821-0671
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 5DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:House Manager - Eduardo ArenasTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Facility is not adhering to dietary restrictions for clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Celine De Perio initiated the 10-day visit to the facility for the complaint received on 5/10/23 and to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by staff on duty who informed house manager (HM) Eduardo Arenas about visit.

During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews and requested copies of pertinent records reviewed.

It was alleged that the facility is not adhering to dietary restrictions for clients. LPA De Perio conducted a total of 3 interviews, which all 3 interviews corroborated with the allegation. It was reported that clients who are on dietary restrictions, were given food that did not adhere to those restrictions. LPA De Perio reviewed the physician report, and individual program plan for client 1 (C1) and client 2 (C2).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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 3
Control Number 22-AS-20230510110552
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: LANEROSE HOME
FACILITY NUMBER: 306002855
VISIT DATE: 05/16/2023
NARRATIVE
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LPA De Perio conducted a tour of the facility and observed that the facility is equipped with the supplies needed to adhere to C1 and C2 dietary restrictions.

Based on LPAs observations, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

For today's visit, a citation was issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with HM Arenas.

A copy of this report, and Appeal Rights were explained and provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230510110552
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: LANEROSE HOME
FACILITY NUMBER: 306002855
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2023
Section Cited
CCR
80076(6)(A)
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80076 Food Services
(6) Modified diets...shall be provided.
(A) The licensee shall... follow instructions from the physician... of the preparation of the modified diet.
This requirement is not met as evidence by:
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As a plan of correction (POC), facility will submit proof of understanding of the regulation cited, to the assigned LPA, and will provide a plan for C1 and C2 to ensure that dietary needs are met for when both clients are not present at the facility, on or by 5/17/23.
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Based on LPA interviews, record review and observation, facility failed to ensure that the modified diets of C1 and C2 were followed due to providing both clients with solid food while attending Day Program.
This poses an immediate health and safety risk for the clients 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.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3