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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002916
Report Date: 01/25/2024
Date Signed: 01/25/2024 03:49:53 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
01/16/2024 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240116114800
FACILITY NAME:ARC FACILITY AT CAMINO 2FACILITY NUMBER:
306002916
ADMINISTRATOR:MICHAEL ADAMSFACILITY TYPE:
740
ADDRESS:2209 CAMINO DEL SOLTELEPHONE:
(714) 870-5830
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 6DATE:
01/25/2024
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Michael Adams-AdministratorTIME COMPLETED:
04:07 PM
ALLEGATION(S):
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Facility is not abiding by Infection Control plan
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 Administrator (AD) Michael Adams. LPA explained the reason for the visit.

On today’s visit LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: During the investigation LPA reviewed documents including the ARC Facility At Camino 2 Plan for Epidemic Outbreak to Covid-19 Mitigation Plan Report dated 12/2020. Per Plan for Epidemic Outbreak to Covid-19 Mitigation Plan Report on page 10 of 28 under Staff it states if staff must cross between designated Covid-19 unit and clear zone, they will be fully trained on appropriate use of PPE. During the initial visit LPA observed that Staff 1 (S1) was not wearing a mask. Per Plan for Epidemic Outbreak to Covid-19 Mitigation Plan Report on page 5 of 28 under Visitors
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: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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 5
Control Number 22-AS-20240116114800
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: ARC FACILITY AT CAMINO 2
FACILITY NUMBER: 306002916
VISIT DATE: 01/25/2024
NARRATIVE
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it states facility has a visitation plan. Records reviewed by LPA Ramirez included the Provider Information Notice (PIN) number 23-13-ASC dated 06/15/23. Per PIN number 23-13-ASC under Visitation it states that for residents in isolation, the licensee should provide the visitor with the same type of Personal Protective Equipment (PPE) used by facility staff. During the course of the interviews AD stated that recently Resident 1 (R1) who is in isolation had a window visit. Per AD the last thing he knew was that visitors were not allowed into the facility.

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: facility is not abiding by Infection Control plan 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 Adams and a copy of this report along with 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: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20240116114800
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: ARC FACILITY AT CAMINO 2
FACILITY NUMBER: 306002916
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2024
Section Cited
CCR
87208(a)(12)
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Plan of Operation (a)Each facility shall have and maintain a current, written definitive plan of operation...The plan and related materials shall contain the following:(12)The Infection Control Plan pursuant to Section 87470. This requirement was not met as evidence by: Based on LPA observations S1 was not
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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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wearing Personal Protective Equipment (PPE) during the initial visit. Based on interviews conducted R1 was not allowed to have an in-person visit. 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: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/16/2024 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240116114800

FACILITY NAME:ARC FACILITY AT CAMINO 2FACILITY NUMBER:
306002916
ADMINISTRATOR:MICHAEL ADAMSFACILITY TYPE:
740
ADDRESS:2209 CAMINO DEL SOLTELEPHONE:
(714) 870-5830
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 6DATE:
01/25/2024
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Michael Adams-AdministratorTIME COMPLETED:
04:07 PM
ALLEGATION(S):
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Facility does not have adequate staffing
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 Administrator (AD) Michael Adams. LPA explained the reason for the visit.

On today’s visit LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Two of three individuals interviewed denied the allegation. During the investigation LPA reviewed documents including the staff schedule dated January 2024. Per staff schedule there are two live-in caregivers for six residents in care. During interviews conducted with residents Resident 1 (R1) stated that staff do a great job and reported that the facility is not understaffed. Per R2 more staff would be useful to help the residents with their needs. During the course of the interviews AD stated that the facility is not understaffed and reported that they have enough staff to
CONTINUED LIC9099-C...
Unsubstantiated
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: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240116114800
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: ARC FACILITY AT CAMINO 2
FACILITY NUMBER: 306002916
VISIT DATE: 01/25/2024
NARRATIVE
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care for the residents.

Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED.

LPA Ramirez conducted an exit interview with AD Adams, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5