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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004250
Report Date: 03/20/2023
Date Signed: 03/20/2023 11:45:13 AM

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
02/11/2022 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220211130803
FACILITY NAME:ESPIRITU GUEST HOME IVFACILITY NUMBER:
306004250
ADMINISTRATOR:CELIA B. MENDOZAFACILITY TYPE:
740
ADDRESS:2602 N. GRAND AVENUETELEPHONE:
(714) 997-9453
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:8CENSUS: 4DATE:
03/20/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Staff Emerson PiscosTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident's bathroom is not wheelchair accessible
Facility does not provide resident with a comfortable bed and mattress
INVESTIGATION FINDINGS:
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Licensing Program Analyst Michelle Reed arrived at the facility to deliver the findings of this complaint investigation. Upon arrival, LPA met with Staff Emerson Piscos. Administrator Celia Mendoza was spoken to via telephone. The complaint was investigated and consisted of interviews with the facility staff, Administrator, Resident #1(R1) and a review of R1’s records. The following was determined:

R1 was admitted into the facility in 2006. R1 used a wheelchair to ambulate and was independent with most of his Activities of Daily Living. R1 could leave the facility unassisted. In November of 2021 R1 had a fall and was hospitalized. According to staff interviewed when R1 returned, he had become bedridden and was unable to transfer into his wheelchair. On 2/18/22 at the time of LPA’s initial visit, LPA noted that the bathroom that R1 used was not wheelchair accessible. The shower has a step that does not allow the wheelchair access. LPA also noted that R1 had a regular mattress on his hospital bed and the mattress was not long enough for the bed. R1 was not comfortable in the bed. Records reviewed disclosed that facility staff had received a Doctor's order for a mattress and had not complied with the order.
Continued:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
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 6
Control Number 22-AS-20220211130803
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: ESPIRITU GUEST HOME IV
FACILITY NUMBER: 306004250
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2023
Section Cited
CCR
87307(d)(1)
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Personal Accomodations and Services- The following space and safety provisions shall apply to all facilities: Sufficient room shall be available to accommodate persons served in comfort and safety.

This requirement was not met as evidenced by:
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Licensee agrees to assess each non-ambulatory resident to ensure that they have comfortable and safe access to the bathroom and/or shower.

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R1’s wheelchair would not fit into the bathroom and there is a step into the shower preventing access.

This poses a potential health and safety/personal rights risk to residents in care.
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Type B
03/21/2023
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:

On 2/18/22 LPA noted that R1 had a regular mattress on his hospital bed and the mattress was not long enough for the bed. R1 was not comfortable in the bed. This posed a personal rights violation to residents in care. LPA also noted that R1 had a prescription for an egg shell mattress and hospital bed dated 12/21/21.
Licensee stated that mattress was obtained after LPA’s 2/18/22 visit. Licensee agrees to fill prescriptions immediately and ensure that residents have comfortable furnishings and equipment as soon as it is discovered that there is a need.
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Licensee agrees to fill prescriptions immediately and ensure that residents have comfortable furnishings and equipment as soon as it is discovered that there is a need.

Mattress was received after initial visit on 2/18/22.


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On 2/18/22 LPA noted that R1 had a regular mattress on his hospital bed and the mattress was not long enough for the bed. R1 was not comfortable in the bed. This posed a personal rights violation to residents 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.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20220211130803
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: ESPIRITU GUEST HOME IV
FACILITY NUMBER: 306004250
VISIT DATE: 03/20/2023
NARRATIVE
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Based upon interviews and LPA’s observations, the preponderance of evidence standard has been met and the allegations are Substantiated.

See LIC9099D for cited deficiencies.

An exit interview was conducted and a copy of this report and appeal rights were given to Emerson Piscos.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
02/11/2022 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220211130803

FACILITY NAME:ESPIRITU GUEST HOME IVFACILITY NUMBER:
306004250
ADMINISTRATOR:CELIA B. MENDOZAFACILITY TYPE:
740
ADDRESS:2602 N. GRAND AVENUETELEPHONE:
(714) 997-9453
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:8CENSUS: 4DATE:
03/20/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Staff Emerson PiscosTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility not maintained clean and sanitary
Facility does not assist resident with obtaining dental care
Resident not receiving showers
INVESTIGATION FINDINGS:
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Licensing Program Analyst Michelle Reed arrived at the facility to deliver the findings of this complaint investigation. Upon arrival, LPA met with Staff Emerson Piscos. Administrator Celia Mendoza was spoken to via telephone. The complaint was investigated and consisted of interviews with the facility staff, Administrator, Resident #1 and a review of Resident #1’s records. The following was determined:

On 2/18/22 LPA toured the physical plant of the facility. Resident rooms were inspected. LPA did not note unclean or unsanitary conditions.

R1 was admitted into the facility in 2006. R1 has a history of stroke and paralysis to left side. R1 used a wheelchair to ambulate and was independent with most of his Activities of Daily Living. Facility staff were asked if R1 receives dental care. Staff stated that they have tried to take R1 to the dentist and he does not want to go. R1 stated that he does not want to go to the dentist as it is painful and his teeth do not bother him. R1 said he is given sponge baths as he cannot get out of bed or transfer into the shower. Staff interviewed stated that they could not move him.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20220211130803
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: ESPIRITU GUEST HOME IV
FACILITY NUMBER: 306004250
VISIT DATE: 03/20/2023
NARRATIVE
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Based upon the interviews conducted, the allegations are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Licensee was reminded that it is the Licensee’s responsibility to ensure that the facility is always clean and sanitary and that medical and dental needs are met for each resident.

An exit interview was conducted and a copy of this report was provided to Staff Emerson Piscos.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
02/11/2022 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220211130803

FACILITY NAME:ESPIRITU GUEST HOME IVFACILITY NUMBER:
306004250
ADMINISTRATOR:CELIA B. MENDOZAFACILITY TYPE:
740
ADDRESS:2602 N. GRAND AVENUETELEPHONE:
(714) 997-9453
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:8CENSUS: 4DATE:
03/20/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Staff Emerson PiscosTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident’s wound
INVESTIGATION FINDINGS:
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Licensing Program Analyst Michelle Reed arrived at the facility to deliver the findings of this complaint investigation. Upon arrival, LPA met with Staff Emerson Piscos . Administrator Celia Mendoza was spoken to via telephone. The complaint was investigated and consisted of interviews with the facility staff, Administrator, Resident #1 and a review of Resident #1’s records. The following was determined:

R1 was admitted into the facility in 2006. R1 has a history of stroke and paralysis to left side. R1 used a wheelchair to ambulate and was independent with most of his Activities of Daily Living. R1 could leave the facility unassisted. In July of 2020 R1 developed a wound on his left foot and Home Health was started and continued through 10/21/22. LPA confirmed with the Home Health agency, the dates of service.

Based upon interviews and a review of records the allegation is unfounded, meaning the allegation is false, could not have happened and/or are without a reasonable basis. R1 was receiving home health services for his wound. An exit interview was conducted and a copy of this report was provided to Emerson Piscos.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
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 6