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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 05:35:01 PM

Substantiated


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
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:
04:21 PM
MET WITH:Nenita MandapatTIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Facility staff lacks experience and training.
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 LPA Haley received a copy of an in service Medication Administration training records from Administrator Cora Kon dated June 29, 2023. During interviews with Staff 1 (S1), LPA Haley was told there has been no training since "before the pandemic." During an interview with Staff 2 (S2), S2 could not recall the last time receiving in service training. LPA Haley asked specifically has Administrator Kon provided any training on medication and was told no by both staff members interviewed. LPA Haley reviewed the training files for staff and there was no current in service training on record. The latest in service training in the training file was titled: Staff Caring for Clients with Seizure Disorders - Dated: 01/11/222
Continued on LIC9099C
Substantiated
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 3
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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The last Medication Administration training certificate in the training file for S1 and S2 was dated February 2019.

It appears the in service training records provided by Administrator Kon were not valid. LPA Haley could not see any record of the training in the staff training records and the staff denied they were provided training.

Based on the evidence gathered through interviews, observation, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1.

An exit review was conducted and copy of this report along with the appeal rights were provided at the time of this visit.

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 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2023
Section Cited
CCR
80065(f)
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All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
This requirement is not being met as evidenced by:
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Administrator Kon will provide verifiable training to staff and forward proof of completion to LPA by POC due date.
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Based on observation, and interview, Administrator Kon failed to ensure staff are trained. In service training records could not be verified by staff. Medication Administration certificates in the training folder was dated February 2019 for Staff 1 and Staff 2.
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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: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

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

DATE: 08/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3