306003953-9-27-2022-22-AS-AJLO-CKQTN3-20221031145205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003953
Report Date: 07/28/2022
Date Signed: 09/27/2022 12:08:27 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
04/05/2022 and conducted by Evaluator Shobhana Frank

COMPLAINT CONTROL NUMBER: 22-AS-20220405100815

FACILITY NAME:	NOHL RANCH ELDERLY CARE III		FACILITY NUMBER:	306003953
ADMINISTRATOR:	GABE/MARIANA CORCHES		FACILITY TYPE:	740
ADDRESS:	2128 E. WHITE LANTERN LANE		TELEPHONE:	(714) 282-8807
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 4	DATE:	07/28/2022
		UNANNOUNCED	TIME BEGAN:	12:22 PM
MET WITH:	Licensee Mariana Corches.		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Resident sustained an injury from a fall while in care
Staff did not provide adequate supervision for a resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Licensee Mariana Corches.
During the course of the investigation, LPA toured the facility, interviews of RP, R1’s daughter in-law, staff 1, R 2and R 3, reviewed and obtained pertinent documentation such as physicians report LIC 603 and admission agreement, VTAS Hospice file.
Based on the reviews of Admission Agreements, daily notes, Physician’s report LIC 602, observation and interview of R 1, R1’s daughter in-law, VITAS caseworker and staff 1 this complaint found to be unfounded. During the interviewed R 2 She stated she resides at the facility for more then 4 years and she couldn't be anywere else. R 3 said that she resides at the facility for one year, she like the facility the licensee takes good care of her. R 1 stated there is nothing to report, she resides at the facility for over 3 years and she is well taking care off by staff. Also interviewed R1’s daughter In-law she said that she did not file a complaint. She

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

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-20220405100815

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: NOHL RANCH ELDERLY CARE III	FACILITY NUMBER: 306003953
	VISIT DATE: 07/28/2022

NARRATIVE

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said that family always found R1 well-being at this board and care to be very good. R1 is well attended to and has never felt neglected and had not fallen before under her care there.
It was an accident that is difficult to avoid in someone her age and decreased mobility. She believes that she is a very good advocate for her mother-in-law and she is confident that her mother in-law gets good care at this facility. VITAS caseworker said Licensee and her staff are good caregivers and the home is very a esthetically pleasing! R1 well cared for.

Based on the collective information, the above allegations are determined unfounded. This agency has investigated the complaint alleging. Resident sustained an injury from a fall while in care and Staff did not provide adequate supervision for a resident, 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. We have therefore dismissed the complaint.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC9099 (FAS) - (06/04)

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