306003385-11-3-2023-22-AS-AORZ-CXK24K-20231113160404

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003385
Report Date: 11/03/2023
Date Signed: 11/03/2023 05:14:51 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
08/11/2020 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200811165052

FACILITY NAME:	FAMILY CHOICE SENIOR CARE 4		FACILITY NUMBER:	306003385
ADMINISTRATOR:	VIRGILIO AGAS		FACILITY TYPE:	740
ADDRESS:	3105 W. ORANGE STREET		TELEPHONE:	(714) 229-0069
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	0	CENSUS: 0	DATE:	11/03/2023
		UNANNOUNCED	TIME BEGAN:	01:48 PM
MET WITH:			TIME COMPLETED:	05:14 PM

ALLEGATION(S):

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-Facility staff failed to follow Needs and Services Plan of resident.
-Facility staff changed the Needs and Services Plan without the authorized representative’s approval.

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz attempted contacting the facility to deliver findings on a complaint investigation via telephone due to facility being closed 12/12/2020. The 10 day virtual inspection visit due to COVID-19 precautionary measures was conducted on 8/20/2020 by LPA Criss Trinidad and LPA Michelle Reed.
During course of the investigation, the Department attempted to interview staff and witnesses as well as review and obtained pertinent documentation, but not limited to the following for Resident 1 (R1): Physician report (LIC 602), Admission Agreement, Identification Form (LIC 601) and Needs and Services Plan (LIC 625).
Regarding the allegation,"Facility staff failed to follow Needs and Services Plan of resident," the course of the investigation revealed the following: Documentation review of Needs and Services Plans dated 4/28/2015, 10/7/2015 and 12/15/2019 and Interviews conducted with two of four intervieweess indicated facility is following resident 1's needs and services plan as indicated on R1's admission agreement dated 2/1/2020 and Needs and Services plan dated 12/15/2019. CONTINUED ON NEXT PAGE...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2023

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-20200811165052

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: FAMILY CHOICE SENIOR CARE 4	FACILITY NUMBER: 306003385
	VISIT DATE: 11/03/2023

NARRATIVE

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CONTINUED...Two of four interviewees indicated "R1's Admission Agreement and Needs and Services Plan signed by Authorized Representative do not indicate 1:1 care services for R1."
Regarding the allegation, "Facility staff changed the Needs and Services Plan without the authorized representative’s approval," the investigation revealed the following: Documentation review of Needs and Services Plan (LIC 625) dated 12/15/2019 and Interviews conducted with two of four interviewees conclude that the signature on Admission Agreement dated 2/1/2020 and Needs and Service Plan- LIC 625 page 4 of 4 under section: Person(s) responsible for finances, affairs, payment for care, legal guardian if any matches the name identified on R1's Identification Form (LIC 601) listed under section 1.
The department has investigated the complaint allegations listed above. Therefore, based on LPA Quiroz's documentation review of pertinent documents and interviews conducted, the allegations "Facility staff failed to follow Needs and Services Plan of resident," and "Facility staff changed the Needs and Services Plan without the authorized representative’s approval" are determined to be UNSUBSTANTIATED. Although the allegations may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violations occurred.
The facility has been closed effective 12/12/2020. Attempts to reach Licensee Jack Carolino to conduct an exit interview were unsuccessful. A copy of this report will be certified mailed to the Licensee’s last known address.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC9099 (FAS) - (06/04)

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