306003460-1-18-2023-22-AS-LADS-CNESRM-20230125130630

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003460
Report Date: 01/18/2023
Date Signed: 01/18/2023 12:07:54 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
12/20/2022 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221220132620

FACILITY NAME:	BASIA RESIDENTIAL CARE		FACILITY NUMBER:	306003460
ADMINISTRATOR:	BARBARA MANCZYK		FACILITY TYPE:	740
ADDRESS:	23931 GOWDY AVENUE		TELEPHONE:	(949) 768-0452
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 5	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	10:53 AM
MET WITH:	Facility Administrator-Joanna Manczyk		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Uncleared adult attending to resident(s).

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA met with Administrator (AD) Joanna Manczyk and stated the purpose of this visit which was to deliver the final findings for the complaint received on 12/20/22 against this facility.

This agency has investigated the complaint alleging that there is an uncleared adult attending to resident(s). LPA De Perio reviewed facility documentation, interviewed staff and residents, and conducted a tour of both the interior and exterior portion of the facility. LPA De Perio observed and verified that there was no indication aside from current residents and live-in administrator, that another individual was residing at facility. LPA De Perio also reviewed documentation such as, but not limited to, staff files and facility payroll, of which all present employees were reflected as having the necessary criminal background clearance.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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-20221220132620

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: BASIA RESIDENTIAL CARE	FACILITY NUMBER: 306003460
	VISIT DATE: 01/18/2023

NARRATIVE

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7 out of the 7 interviews all stated that individual in allegation, does not live, work, provide care for residents nor assist staff. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

For today’s visit, no citations were issued. No deficiencies were issued. LPA De Perio conducted an exit interview with AD and copy of this report was left in this facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

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