306003594-6-14-2023-22-AS-SSAS-CT93Q7-20230628182641

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003594
Report Date: 06/14/2023
Date Signed: 06/14/2023 11:14:08 AM

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
01/30/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230130101538

FACILITY NAME:	LOIS GUEST HOME II		FACILITY NUMBER:	306003594
ADMINISTRATOR:	MARICEL WRIGHT		FACILITY TYPE:	740
ADDRESS:	17562 MEDFORD AVENUE		TELEPHONE:	(714) 573-7697
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	6	CENSUS: 6	DATE:	06/14/2023
		UNANNOUNCED	TIME BEGAN:	08:48 AM
MET WITH:	Caregiver- Esther Forsyth		TIME COMPLETED:	11:37 AM

ALLEGATION(S):

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Resident was inappropriately touched while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver findings for the complaint received on January 30, 2023. LPA arrived at the facility, explained the purpose of today’s visit and was granted entry by staff on duty who contacted facility administrator (AD) Louie Dormido. AD Dormido was unable to be present during the time of visit, but provided consent for staff on duty (S1) Esther Forsyth to receive and sign report.

The complaint was investigated by the Department. Findings are based upon this investigation which included record reviews and interviews.

It is alleged that a resident was inappropriately touched while in care. The investigation revealed that the resident reported being touched by a female caregiver around the private area during a shower, however, the caregiver denies the allegation, and stated that the resident can wash own body.

Unsubstantiated

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: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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-20230130101538

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: LOIS GUEST HOME II	FACILITY NUMBER: 306003594
	VISIT DATE: 06/14/2023

NARRATIVE

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The resident was then interviewed a second time, and reported that the caregiver was a male, and only the inner thigh was touched. Per resident’s physician reports dated September 18, 2022, revealed that the resident is not diagnosed for dementia but with behaviors of being confused and forgetful.

Based on the information gathered during the investigation, review of documents obtained, and due to the conflicting information obtained, the Department unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

No citation is issued.

An exit interview was conducted with S1 and AD via phone call. A copy of this report was explained and provided during the visit.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC9099 (FAS) - (06/04)

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