306002879-8-12-2022-22-AS-SSAS-CHS3NZ-20220829182444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002879
Report Date: 08/12/2022
Date Signed: 08/12/2022 04:04:30 PM

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
08/03/2022 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220803105119

FACILITY NAME:	FLAMINGO CARE HOME		FACILITY NUMBER:	306002879
ADMINISTRATOR:	MARYJEAN ALVARADO		FACILITY TYPE:	740
ADDRESS:	11821 FLAMINGO DRIVE		TELEPHONE:	(714) 591-5439
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	0	CENSUS: 0	DATE:	08/12/2022
		UNANNOUNCED	TIME BEGAN:	03:36 PM
MET WITH:	Luminous Ibarrientos - Licensee		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Facility failed to provide resident records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez and Licensing Program Manager (LPM) Sheila Santos conducted an Office meeting with Licensee Luminous Ibarrientos at the Orange Regional Office. The purpose of this meeting was to deliver the findings of the investigation into the above allegation due to the facility being closed.

During today's meeting Licensee Ibarrientos again confirmed that she had not supplied the records requested. During the investigation LPA Velazquez conducted interviews with Licensee Ibarrientos who indicated she was informed that a request for records had been received. The records reviewed included a letter from the Law Office of Garcia & Artigliere dated June 28, 2022 requesting Resident (R) #1's records, an Authorization for the Release of Medical Information from the Law Office of Garcia & Artigliere executed on June 23, 2022, medication documentation, Physician's report, Appraisal Needs and Services Plan, Personal Rights, and Centrally Stored Medication and Destruction Record.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

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-20220803105119

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: FLAMINGO CARE HOME	FACILITY NUMBER: 306002879
	VISIT DATE: 08/12/2022

NARRATIVE

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Based on the observations made, interviews which were conducted, and the records reviewed, the preponderance of evidence standard has been met, therefore the allegation of Facility failed to provide resident records, is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 is being cited on the attached LIC 9099 D.

An exit interview was conducted with Licensee Luminous Ibarrientos and a copy of this report along with the appeal rights, LIC 9098 and LIC 811 were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20220803105119

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: FLAMINGO CARE HOME	FACILITY NUMBER: 306002879
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/19/2022 Section Cited HSC 1569.269(a)(21)	1 2 3 4 5 6 7	Enumerated rights; severability. Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met as evidenced by the Licensee's failure to provide R1's records to their legal representative. This poses a potential risk to the health & safety of residents in care.	1 2 3 4 5 6 7	Licensee to provide the Law Office of Garcia & Artigliere with copies of R1's records by August 19, 2022. Licensee to provide written proof to LPA by POC due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC9099 (FAS) - (06/04)

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