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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002916
Report Date: 07/25/2024
Date Signed: 07/25/2024 11:16:35 AM

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
07/18/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240718090547
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:
07/25/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Mike AdamsTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff refuses to assist resident with transfers
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with the Administrator Mike Adams and explained the reason for the visit. The investigation into the allegation revealed the following. LPA interviewed Resident 1 (R1). R1 reported that the Administrator refused to assist them transfer out of bed since they are non-ambulatory. The Administrator verified this report. R1 and the Administrator reported that the fire department was called and they responded to the facility on July 24, 2024. R1 and the Administrator verified that R1 was transferred with the help of the firemen on July 24, 2024. The Administrator reported that at the time they could not assist R1 because of back issues. Based on the evidence gathered through interviews the preponderance of evidence standard has been met therefore the allegation is substantiated. Deficiencies are cited are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report was provided along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
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 2
Control Number 22-AS-20240718090547
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: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
87464(f)(4)
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Basic Services. Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal with those activities of daily living such as dressing, eating, bathing...
, as specified in Section 87608...This requirement is not being met as evidenced by:
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Licensee agrees to transfer all residents when they request assistance. LIcensee agrees to submit a statement of understanding for CCR 87464 Basic Services.
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Based on interviews the Administrator did not transfer R1 on July 24, 2024 when they requested to be transferred, This poses an immediate health and safety risk to residents 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: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2