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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003421
Report Date: 09/14/2022
Date Signed: 09/14/2022 01:25:45 PM

Unfounded


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
08/24/2022 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220824092908
FACILITY NAME:SOUTH HOME CAREFACILITY NUMBER:
306003421
ADMINISTRATOR:ADELA ALBUFACILITY TYPE:
740
ADDRESS:2779 E. DIANA AVENUETELEPHONE:
(714) 630-5744
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 6DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Stephanie IlkTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff hit resident
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Facility Staff (S1) Stephanie Ilk and explained the reason for today’s inspection. Administrator (AD) Adela Albu appeared via telephone. The investigation into the allegation that Staff hit resident revealed the following: During the course of the investigation, LPA interviewed AD, staff, and witnesses, and requested and reviewed Resident #1’s (R1) Resident File and other facility records.

Interviews with AD, staff, and witnesses revealed that on 08/22/22, R1 experienced a mental health crisis which resulted in R1 being hospitalized on a 5150 hold. It was reported that, during R1’s mental health crisis, R1 stated that facility staff had hit R1 and otherwise abused R1, but that R1 provided no details about these statements and also made other statements which appeared “manic”. In interviews, AD and staff denied that R1 or any other resident had ever been hit or abused at the facility and stated R1’s statements were not true.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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 5
Control Number 22-AS-20220824092908
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: SOUTH HOME CARE
FACILITY NUMBER: 306003421
VISIT DATE: 09/14/2022
NARRATIVE
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R1’s responsible party heard R1 make the reported statements, but stated that R1’s statements were not true, that R1 made multiple untrue statements about the facility and R1’s family during their mental health crisis, and that R1’s statements were “delusions”. R1’s responsible party also stated that as of 08/30/22 R1’s 5150 hold had been extended to a 5250 hold and that R1 was still receiving mental health treatment at a hospital. All interviews conducted revealed that R1’s statements were not true and were manifestations of R1’s mental health crisis.

The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/24/2022 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220824092908

FACILITY NAME:SOUTH HOME CAREFACILITY NUMBER:
306003421
ADMINISTRATOR:ADELA ALBUFACILITY TYPE:
740
ADDRESS:2779 E. DIANA AVENUETELEPHONE:
(714) 630-5744
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 6DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Stephanie IlkTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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9
Staff prevented resident from leaving facility
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Facility Staff (S1) Stephanie Ilk and explained the reason for today’s inspection. Administrator (AD) Adela Albu appeared via telephone. The investigation into the allegation that Staff prevented resident from leaving facility revealed the following: During the course of the investigation, LPA interviewed AD, staff, and witnesses, and requested and reviewed Resident #1’s (R1) Resident File and other facility records.

Interviews with AD, staff, and witnesses revealed that on 08/22/22, R1 experienced a mental health crisis. AD stated that R1 became agitated and tried to leave the facility while AD and the 2 staff members present tried to redirect R1 and AD called 911. In interviews, AD and staff stated that when R1 tried to leave through the front door, a staff member held the door closed for about 15 to 30 minutes to prevent R1 from leaving and to ensure R1’s safety during the mental health crisis.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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 5
Control Number 22-AS-20220824092908
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: SOUTH HOME CARE
FACILITY NUMBER: 306003421
VISIT DATE: 09/14/2022
NARRATIVE
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While the staff member held the door closed, R1 hit the staff member twice on the arm and once in the face, at which point AD advised staff to allow R1 to leave but to follow R1 to ensure R1’s safety. AD, staff, and witnesses stated that after R1 left the facility, R1 walked to the neighboring home where R1 was met by AD and the police. After additional attempts to redirect R1 and additional calls by AD to authorities, R1 was hospitalized on a 5150 hold. AD stated that staff temporarily prevented R1 from leaving the facility to ensure R1’s safety, the facility had never before experienced a resident elopement or mental health crisis, and AD did their best to address the situation and seek guidance from the proper authorities. In addition, R1’s responsible party has no complaints about how the facility handled R1’s mental health crisis, supports the facility’s efforts to ensure R1’s safety, and stated that the facility and its staff are “lovely”. However, the fact remains that facility staff prevented R1 from leaving the facility for 15 to 30 minutes which resulted in R1 attacking a staff member.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20220824092908
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: SOUTH HOME CARE
FACILITY NUMBER: 306003421
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2022
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights … (a) Residents … shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises… This requirement was not met as evidenced by:
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Licensee stated they will create an elopement protocol, train all staff on the protocol, and send the protocol and proof of training to LPA by POC due date.
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Based on interviews, the licensee did not ensure R1’s ability to leave the facility when a staff member temporarily prevented R1 from leaving which resulted in an altercation, which poses a potential personal rights 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.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5