306002879-8-12-2022-22-AS-SSAS-CHS3TM-20220829183209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002879
Report Date: 08/12/2022
Date Signed: 08/12/2022 03:44:19 PM

Unsubstantiated

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
08/06/2020 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200806111511

FACILITY NAME:	FLAMINGO CARE HOME		FACILITY NUMBER:	306002879
ADMINISTRATOR:	LUMINOUS IBARRIENTOS		FACILITY TYPE:	740
ADDRESS:	11821 FLAMINGO DRIVE		TELEPHONE:	(714) 539-6065
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	0	CENSUS: 0	DATE:	08/12/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Luminous Ibarrientos - Licensee		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained injury while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 the investigation LPA Velazquez conducted interviews with Licensee Ibarrientos, former facility staff and the resident's responsible party. The individuals interviewed provided conflicting statements and could not corroborate the allegation of resident sustained an injury while in care. LPA Velazquez also reviewed resident records which included an admissions agreement, physician's report, centrally stored medication and destruction record, UC Irvine Health records, Appraisal Needs and Service Plan, and Southern California Hospital Behavioral Health Unit records. The records indicated the resident had a history of Schizophrenia, Bipolar Disorder, and Seizure Disorder.

Unsubstantiated

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)

Page: 1 of 2

Control Number 22-AS-20200806111511

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Velazquez was also provided pictures documenting ecchymosis on resident's right upper extremity and the right side of their upper body but the date of the pictures could not be verified as there was no date stamp. The staff interviewed could not recall the resident sustaining an injury at the facility.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the following allegation: Resident sustained injury while in care is deemed UNSUBSTANTIATED.

An exit interview was conducted with Licensee Luminous Ibarrientos and a copy of this report along with the 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 2