306003468-2-10-2023-22-AS-SSAS-CPC3EE-20230223171101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003468
Report Date: 02/10/2023
Date Signed: 02/10/2023 03:52:36 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
02/07/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230207140526

FACILITY NAME:	MARY'S HOME		FACILITY NUMBER:	306003468
ADMINISTRATOR:	GLORIA V. UY		FACILITY TYPE:	735
ADDRESS:	1440 S. EASY WAY		TELEPHONE:	(714) 778-3901
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	6	CENSUS: 3	DATE:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Jean Camacho, House manager (via phone) Gloria Uy, licensee (via phone) Lolita Camacho, caregiver Eduard Camacho, caregiver		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Facility conducted an unlawful eviction.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unnanounced visit for the purpose of investigating the allegation listed above. LPA was greeted and granted entry by caregiver Lolita Camacho after explaining the purpose of the visit and listing the allegation. LPA then spoke with Jean Camacho, House Manager and Gloria Uy, licensee, via telephone. Licensee agreed to conduct the review of the report along with exit interview via phone prior to authorizing the caregiving staff to sign on her behalf.

LPA requested and obtained the client records for clients C1 and C2 along with facility behavior notes on client C1. Staff members S1 and S2 were interviewed at the facility in addition to house manager and licensee. Client C2 was also present and interviewed. Additional witness interviews were conducted by telephone prior to conducting the facility visit. LPA accompanied by caregiver toured the physical plant.

CONTINUED ON FORM LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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-20230207140526

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MARY'S HOME	FACILITY NUMBER: 306003468
	VISIT DATE: 02/10/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099

Regarding the allegation that Facility conducted an unlawful eviction, the following has been determined: Following multiple unreported behavior episodes by client C1, facility staff and administrator notified the client's conservators as well as the Regional Center of Orange County (RCOC) of the intent to submit a 30-day eviction notice due to the client's disruptive behavior. Licensee indicates that a written notice to that extent was submitted to RCOC on or around January 2, 2023 and that no written notices were communicated to the client's conservatorship.

When client C1's family came to pick her up on the January 4, 2023, facility staff verbally informed the client's relative that the client could not be allowed to return to the facility due to her violent and disruptive behavior. No prior approval to that extent was sought from the licensing agency and/or obtained by the licensee.

It was additionally established that following the verbal notice, the client never returned to the facility. Regardless of the circumstances and behavior issues described by multiple interviewees, the required steps towards an eviction procedure were observed to not have been met by the facility prior to requesting the removal of the client from the premises.

Based on interviews conducted, a review of records provided at the facility and admission by the licensee, the allegation that Facility conducted an unlawful eviction is deemed Substantiated, meaning that the preponderance of evidence standard has been met.

One deficiency is cited today per Title 22, of the California Code of Regulations. One Technical Violation advisory is additionally issued regarding Reporting Requirements of any unusual incident which threatens the physical or emotional health or safety of any client.

An exit interview was conducted via telephone and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230207140526

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MARY'S HOME	FACILITY NUMBER: 306003468
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/11/2023 Section Cited CCR 85068.5(a)	1 2 3 4 5 6 7	The California Code of Regulations Section 85068.5(a) on Eviction Procedures states that: "The licensee shall be permitted to evict a client by serving the client with a 30-day written notice to quit." This requirement is not met as evidenced by: No written notice was issued to the client prior	1 2 3 4 5 6 7	Licensee to review the regulatory requirements for eviction and provide an in-service training to all staff regarding the adequate procedure required prior to conducting a client's eviction.
	8 9 10 11 12 13 14	to requesting her physical removal from the facility on January 4, 2023. Based on records reviewed and interviews conducted, the licensee did not comply with the section cited above which poses/posed an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

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