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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003432
Report Date: 08/28/2023
Date Signed: 08/28/2023 05:34:07 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
08/02/2023 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230802122527
FACILITY NAME:EMBASSY RESIDENTAL CAREFACILITY NUMBER:
306003432
ADMINISTRATOR:CORA KONFACILITY TYPE:
735
ADDRESS:1809 W. EMBASSY AVENUETELEPHONE:
(714) 758-3677
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 3DATE:
08/28/2023
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Nenita MandapatTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Facility did not maintain a comfortable indoor temperature.
Facility did not provide bedsheets to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to deliver the findings on the complaint allegation above.

The initial unannounced complaint visit was completed August 3, 2023. The complaint investigation consisted of interviews, observations, and document review.
During the investigation into the complaint allegtions above, the air conditioner in the facility was observed to be working. During the intial visit the temperature in the facitliy was 77 degrees fahrenheit. During the second visit the temperature in the facility was 81 degrees fahrenheit and LPA Haley asked Staff 2 (S2) to lower the temperature on the air conditioning unit. LPA observed staff lower the temperature of the unit to ensure the unit was working properly.

While observing client bedrooms, LPA Haley observed sheets on the clients beds during both visits to the facility. During the initial visit C1's sheets were balled up on the corner of the bed. During the second visit
Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
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-20230802122527
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: EMBASSY RESIDENTAL CARE
FACILITY NUMBER: 306003432
VISIT DATE: 08/28/2023
NARRATIVE
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C1's sheets were in his drawer. C1 was observed in his room with the windows closed and a fan was turned on. LPA Haley opened the blinds and open the window in the room. C1 said he doesn't like the window and the blinds open. C1 was laying on the floor in the room and said he was laying on the floor because it was too hot.

Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is Unsubstantiated.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2