306004058-6-23-2023-22-AS-SSAS-CT9PME-20230629112612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004058
Report Date: 06/23/2023
Date Signed: 06/23/2023 11:19:38 AM

Unsubstantiated

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
06/05/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230605111542

FACILITY NAME:	INFINITY HOME CARE		FACILITY NUMBER:	306004058
ADMINISTRATOR:	DINA LUCACIU		FACILITY TYPE:	740
ADDRESS:	26051 CAMINO ADELANTO		TELEPHONE:	(949) 859-6019
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS:	DATE:	06/23/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dina Lucaciu, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not provide resident's authorized representative with an itemization of charges for rate increase.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA was greeted and granted entry into the facility by caregiving staff after introducing himself and stating the purpose of the visit. Administrator Dina Lucaciu was notified via telephone and arrived shortly afterwards to assist with the visit.

On June 12, 2023, LPA conducted an initial investigation visit at the facility. LPA accompanied by caregiver conducted a brief tour of the facility's physical plant. Additionally, LPA requested and obtained resident records for resident R1 along with the five individuals currently in care. Additional records were obtained after the visit.

CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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-20230605111542

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: INFINITY HOME CARE	FACILITY NUMBER: 306004058
	VISIT DATE: 06/23/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099

Regarding the allegation that Staff did not provide resident's authorized representative with an itemization of charges for rate increase, the following has been concluded: Based on interviews conducted and records reviewed, it was corroborated that resident R1 suffered a change in condition and the onset of vascular dementia since her medical assessment conducted on February 25, 2020 prior to her admission at the facility. An updated medical assessment was requested from the resident's primary care physician in April 2023 and an examination was made on May 4, 2023. The update confirmed the primary diagnosis of vascular dementia and the dementia diagnosis on a completed form LIC602. Evidence of this change in condition being notified to the resident's responsible party prior to the rate for basic services being adjusted was also provided by facility staff, further corroborating the fact that the newly adjusted rate was being charged in response to the change in condition described. The allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred.

A Technical Violation Advisory Note is however issued in the attached form LIC9102 to the facility and a consultation is provided by LPA in order to remind the licensee of the regulations applicable to the Admission agreement and rated charged to the residents in care.

An exit interview was conducted and a copy of this report was emailed and provided to facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC9099 (FAS) - (06/04)

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