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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003744
Report Date: 10/06/2023
Date Signed: 10/06/2023 05:48:00 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
09/10/2020 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200910153105
FACILITY NAME:QUALITY CARE PLUSFACILITY NUMBER:
306003744
ADMINISTRATOR:MARJAN ARASTOOFACILITY TYPE:
735
ADDRESS:1652 W. BROADWAYTELEPHONE:
(714) 635-6561
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:80CENSUS: 69DATE:
10/06/2023
UNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Marjan ArastooTIME COMPLETED:
06:02 PM
ALLEGATION(S):
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Facility did not have any client records.
Facility is unsanitary.
Lack of qualified staff to meet client needs.
Facility did not follow admission procedure.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Marjan Arastoo and explained the reason for the visit. The investigation into the allegation, facility did not have any client records, revealed the following. It was reported that the facility did not have Client 1’s (C1) records when requested by C1’s case manager. The facility Administrator reported that the facility did have the records they were just misplaced and were eventually provided to the case manager. A review of C1’s records from the facility showed that C1 had the following documents in their facility file, A copy of house rules signed by C1, signed consent to a medical examination, signed release of client/resident medical information, signed personal rights, signed notification for Health and Safety Code 1564 and 1522.1, physician’s report dated 8/14/20, Medication Administration Record (MAR) for August 2020, Emergency Contact information (no one is listed except C1), page 1 of C1’s admission agreement (4 pages, including the signature page were missing), appraisal/needs and service plan which is incomplete.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
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 7
Control Number 22-AS-20200910153105
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: QUALITY CARE PLUS
FACILITY NUMBER: 306003744
VISIT DATE: 10/06/2023
NARRATIVE
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No specific information for C1 was in the plan. C1’s facility records were incomplete. Based on the evidence gathered through interviews and a review of records the preponderance of evidence standard has been met, therefore the above allegation is substantiated.

Regarding the allegation, facility is unsanitary, the investigation revealed the following. Licensing Program Analysts (LPAs) Ruth Martinez and Sean Haddad conducted the initial 10-day visit to begin the complaint investigation on 8/27/20. LPA Haddad observed the following during the visit, the front porch was covered in cigarette butts, ash and other dirt. LPA observed mold in the showers in the second-floor bathrooms. LPA observed a dirty broken microwave and 3 dirty vending machines in the lobby. Based on the evidence gathered through observations the preponderance of evidence standard has been met, therefore the above allegation is substantiated.

The investigation into the allegation, lack of qualified staff to meet client needs, revealed the following. It was alleged that the facility did not have enough staff to provide care and supervision for all of the clients at the facility. On 8/27/20 there was an incident in which Client 1 (C1) was having a behavior episode and Staff 1 (S1) called 911. C1 and S1 are no longer associated with the facility and their contact information is no longer valid. C1 and S1 could not be reached to be interviewed. The Administrator reported that at the time of the incident the only Staff member on duty was S1. The number of clients at the facility at the time of the incident was reported to be 75 clients. At the time of the 10-day visit the facility census was 73 clients. The Administrator reported that the census at the time of the incident was 75. One staff member is not sufficient to meet the needs of all the clients especially when there is an emergency that requires staff to call 911. Based on the evidence gathered the preponderance of evidence standard has been met, therefore the above allegation is substantiated.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 22-AS-20200910153105
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: QUALITY CARE PLUS
FACILITY NUMBER: 306003744
VISIT DATE: 10/06/2023
NARRATIVE
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Regarding the allegation, facility did not follow the admission procedure, the investigation revealed the following. It was reported that the facility did not follow the proper admission procedure for Client 1 (C1). The client was at College Hospital Costa Mesa prior to their admission to Quality Care Plus. No specific details were provided as to what the facility did not do regarding their admission procedure. The only information provided was that the files of the clients were unorganized. A file review for the facility’s plan of operation shows their admission procedure is as follows, interview prospective client, clients tour of facility if possible, Administrator ensures resident is compatible with other residents, Administrator ensure that client understands the Board and Care living and is willing to live in a board and care environment, Administrator to ensure that resident and their placement agent understand that board and care has house rules that are to be followed, facility shall obtain a written medical assessment performed by a licensed physician, licensee shall complete a needs and services plan for each client and if admission is agreed to, facility shall obtain signature of client, his/her authorized placement agent, and conservator, if any, on the admission agreement. C1 could not be reached for interview and the Administrator reported they do not remember admitting the client since it was over 3 years ago. It is unknown if all the steps for the admission procedure were followed but a review of C1’s records show that the last two steps of the procedure, licensee shall complete a needs and services plan for each client and facility shall obtain signature of client were not followed. C1’s needs and services plan does not list any specific details with information from their written assessment from College Hospital Costa Mesa and provides no details as to how the facility staff will help C1 because of their poor coping skills and tendency to be aggressive. The admission agreement for C1 only had one page, 4 pages including the signature page were missing, so based on a record review the facility never obtained C1’s signature. Based on the evidence gathered the preponderance of evidence standard has been met therefore the above allegation is substantiated.

Violations are being cited per California Code of Regulations, Title 22 division 6. An exit interview was conducted and a copy of the report provided along with appeal rights.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 22-AS-20200910153105
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: QUALITY CARE PLUS
FACILITY NUMBER: 306003744
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2023
Section Cited
CCR
85065(b)
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The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. This requirement was not met as evidenced by...
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Licensee agrees to always have enough staff on duty to meets the needs of clients. Licensee to forward staff schedules and staff pay reports to verify there is sufficient staff on duty by 10/13/23.
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As reported by facility staff there was only 1 staff present at the facility during an emergency that required staff to call 911, when there was 75 clients, which poses an immediate health and safety risk to clients in care.
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Type A
10/07/2023
Section Cited
CCR
85068.2(b)
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If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan...
This requirement was not met as evidenced by,
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Licensee agrees to train staff on CCR 85068.2 and to submit proof of training by 10/16/23.
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Based on a review of records for Client 1 there was not a completed Needs and Service plan. The plan did not list any specific information pertaining to Client 1 or their behaviors. This poses an immediate health and safety risk to clients in care.
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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: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 22-AS-20200910153105
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: QUALITY CARE PLUS
FACILITY NUMBER: 306003744
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2023
Section Cited
CCR
80087(a)
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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by,
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Licensee agrees to keep the facility clean and sanitary at all times. This deficiency has been corrected since the complainat has been filed. Proof of correction will be completed by the LPA and provided to the facility.
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LPA Haddad observed the following during the 10-day visit, the front porch was covered in cigarette butts, ash and other dirt. This poses a potential health and safety risk to clients in care.
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Type B
10/13/2023
Section Cited
CCR
80022(k)
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The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so. This requirement was not met as evidenced by.
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Licensee agrees to train all staff on CCR 80022 and 80068. Licensee to submit proof of training to LPA by 10/16/23.
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A review of facility records shows the facility did not follow their plan of operation by not obtaining the client signature of Client 1 on the admission agreement as specified in their plan of operation. This poses a potential health and safety risk to clients in care.
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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: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
09/10/2020 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200910153105

FACILITY NAME:QUALITY CARE PLUSFACILITY NUMBER:
306003744
ADMINISTRATOR:MARJAN ARASTOOFACILITY TYPE:
735
ADDRESS:1652 W. BROADWAYTELEPHONE:
(714) 635-6561
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:80CENSUS: 69DATE:
10/06/2023
UNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Marjan ArastooTIME COMPLETED:
06:02 PM
ALLEGATION(S):
1
2
3
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5
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9
Client missed medication.
Staff did not follow emergency plan.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Marjan Arastoo and explained the reason for the visit. The investigation into the allegation, client missed medication, revealed the following. Client 1 (C1) could not be interviewed because their whereabouts are unknown and there emergency contact information did not list a phone number. The Administrator reported that C1 received all of their prescribed medications. A review of C1's MAR for August 2020 shows C1 did not miss any prescribed medication for the days they were at the facility. Based on the evidence gathered the allegation is deemed Unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

Regarding the allegation, staff did not follow emergency plan, the investigation revealed the following.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20200910153105
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: QUALITY CARE PLUS
FACILITY NUMBER: 306003744
VISIT DATE: 10/06/2023
NARRATIVE
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It was reported that the staff did not follow the emergency plan when C1 was having a behavior episode. On 8/27/20 C1 was having a behavior episode and was becoming aggressive toward Staff 1. Staff 1 is no longer employed at the facility and their contact information is no longer valid. Staff 1 was not interviewed. C1 became agitated and was acting aggressively toward Staff 1. Staff 1 attempted to move away from C1 but C1 continued to act aggressively. Staff 1 called 911 and went in a bathroom and locked the door to get away from C1. First responders arrived and C1 was placed on a 5150 hold and transported to a hospital to be evaluated. C1 never returned to the facility. 3 out of 3 clients interviewed who lived at the facility at the time of the incident did not remember the incident. It is unclear what steps Staff 1 did when the incident began and there is not enough information from witnesses to know exactly what happened. What is clear is that Staff 1 called 911 and first responders arrived and put C1 on a 5150 hold and transported them to the hospital. C1 no longer resides at the facility and their whereabouts are unknown so C1 was not interviewed. According to the plan of operation for the facility, staff are to call 911 immediately for Life threatening Emergencies and then call the client’s doctor, family, or guardian. According to witnesses C1 was put on a 5150 hold because they were a danger to others. Staff followed the first step but because C1 did not have any listed emergency contacts it is unknown if C1's family was contacted by anyone. The Administrator reported that they didn't have any contacts for C1. Based on the evidence gathered the allegation is deemed Unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of the report provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7