306003830-10-31-2023-22-AS-SSAS-CX62RM-20231031173747

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003830
Report Date: 10/31/2023
Date Signed: 10/31/2023 02:56:37 PM

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
12/22/2020 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201222153845

FACILITY NAME:	DEL OBISPO TERRACE SENIOR LIVING		FACILITY NUMBER:	306003830
ADMINISTRATOR:	SABRINA PRIESMAN		FACILITY TYPE:	740
ADDRESS:	32200 DEL OBISPO		TELEPHONE:	(949) 496-8802
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY:	0	CENSUS: 0	DATE:	10/31/2023
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:			TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Resident was left in soiled clothing for an extended period of time
Resident is not provided adequate food service
Residents are left to sleep in wheelchairs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre completed the investigation into the allegations listed above. The facility is closed and no longer operating so the LIC 9099 is being sent to the address on record for the Licensee via certified mail.

The investigation into the allegation, resident was left in soiled clothing for an extended period of time, revealed the following. It was alleged Resident 1 (R1) was left in clothing soiled in urine and staff did not assist the resident. No specific details were provided as to when or where this took place. 3 out of 3 staff interviewed denied this report. R1 and R1’s responsible party could not verify this report. 2 other residents interviewed, who use wheelchairs, reported no issues regarding assistance with toileting. There is no evidence to support the allegation, therefore the allegation, resident was left in soiled clothing for an extended period of time 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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-20201222153845

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: DEL OBISPO TERRACE SENIOR LIVING	FACILITY NUMBER: 306003830
	VISIT DATE: 10/31/2023

NARRATIVE

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The investigation into the allegation, resident is not provided adequate food service, the investigation revealed the following. No specific details were provided regarding this allegation. R1 reported they liked the food at the facility and has no issues with the food. 2 other residents interviewed reported they had no issues with the food at the facility. 3 out of 3 staff interviewed and the Administrator reported that they have not received any complaints about the food. There is no evidence to support the allegation, therefore the allegation, resident is not provided adequate food service 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.

The investigation into the allegation, residents are left to sleep in wheelchairs, revealed the following. No specific details were provided with this allegation. 3 out of 3 residents who use wheelchairs could not verify this report. 3 out of 3 staff interviewed and the Administrator reported that residents are not allowed to sleep in wheelchairs due to possible safety and health concerns. There is no evidence to support the allegation, therefore the allegation, residents are left to sleep in wheelchairs 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.

The LIC 9099 is being sent to the last known address of the Licensee via certified mail.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC9099 (FAS) - (06/04)

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