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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002916
Report Date: 08/06/2024
Date Signed: 08/06/2024 06:39:06 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
07/30/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240730135947
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:
08/06/2024
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Mike AdamsTIME COMPLETED:
06:31 PM
ALLEGATION(S):
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Facility is mismanaging medication
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 allegations above. LPA and the Administrator toured the facility. LPA interviewed staff and residents. The investigation into the allegation facility is mismanaging medication revealed the following. It was reported that Resident 1 (R1) ran out of their Venlafaxine 225MG. R1 verified they ran out of the medication on or around July 14, 2024. The Administrator verified this report. At this time the facility was handling R1's medication. Both the Administrator and R1 verified this information. A review of medication records show R1's medication arrived at the facility on July 31, 2024. R1 did not have their Venlafaxine 225MG for 16 days. LPA reviewed R1's medication. No other discrepancies observed. Based on the information gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulation. An exit interview was conducted and a copy of the report provided along with appeal rights was provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
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 3
Control Number 22-AS-20240730135947
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: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2024
Section Cited
CCR
87468.1(a)(16)
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To receive or reject medical care or other services. This requirement is not being met as evidenced by...
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Licensee agrees to retrain staff on medication management. Licensee agrees to set policies in place to properly have medication reordered prior to residents running out of medication. Licensee to submit proof of training and a new medication policy to LPA.
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R1 ran out of their Venlafaxine 225MG for 16 days which poses an immediate health, safety and personal rights 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: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
07/30/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240730135947

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:
08/06/2024
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Mike AdamsTIME COMPLETED:
06:31 PM
ALLEGATION(S):
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Facility is in disrepair
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 above. LPA and the Administrator toured the facility. LPA interviewed staff and residents. The investigation into the allegation facility is in disrepari revealed the following. On or around July 30 bathroom 1 in the facility had a water leak on the toilet. While in the bathroom R1 reported the toilet started leaking. Staff assisted R1 out of the bathroom and shut off the water to the toilet. The Administrator and 3 residents interviewed verified this information. The Administrator reported that the toilet was fixed in 2 hours and staff cleaned the bathroom and hallway. 3 residents interviewed verified this report. LPA observed the bathroom is clean and operational and the toilet is not leaking any water. Based on the information provided the allegation is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3