306004296-6-20-2023-22-AS-SSAS-CT93LH-20230628182045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004296
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:24:07 PM

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
06/19/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230619105359

FACILITY NAME:	PIERCE ADULT RESIDENTAL CARE HOME		FACILITY NUMBER:	306004296
ADMINISTRATOR:	ROMMEL MENDOZA		FACILITY TYPE:	735
ADDRESS:	3112 PIERCE AVENUE		TELEPHONE:	(714) 556-5102
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 3	DATE:	06/20/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lordetha Bonilla, lead care staff		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility is not maintained clean and sanitary.

Staff do not meet residents' dietary needs.

Staff yell at residents.

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 conducting an initial investigation into the three allegations listed above. LPA was greeted and granted entry into the facility by direct care staff present after introducing himself along with the reason for the visit. Lead care staff Lordetha Bonilla was notified of the visit via telephone but was unable to assist in person as she is currently on sick leave. LPA detailed the allegation investigated to the lead care staff via telephone and offerred to go over the final report before having one of the direct care staff members present sign. Lead actually arrived later to assist with the visit.

LPA accompanied by caregiver conducted a tour of the physical plant. The facility is observed to be a somewhat older home, however it is kept clean. Both floors and surfaces are observed to be clean and free of dirt and debris as LPA was able to document in photographs.
CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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-20230619105359

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: PIERCE ADULT RESIDENTAL CARE HOME	FACILITY NUMBER: 306004296
	VISIT DATE: 06/20/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099

LPA requested, obtained and reviewed staff records on file for the five currently active staff members along with the client files for the three clients currently residing at the facility. An additional interview was conducted by telephone during the visit.

Regarding the allegation that Facility is not maintained clean and sanitary, the following has been concluded: LPA observed clean floors and surfaces throughout the facility, with no evidence of dirt or debris. Interviews conducted corroborated the fact that this is the usual condition of the house, despite the building itself being a somewhat older home. Therefore the allegation is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

Regarding the allegation that Staff do not meet residents' dietary needs, the following has been concluded: LPA observed the conclusion of the lunch service as well as the preparations for dinner on the day of the visit. Clients were confirmed to have been provided with balanced meals including fruits and vegetables as per the menu posted on the kitchen's refrigerator. Interviews conducted confirmed that food service was in compliance with dietary needs. As a result, the allegation is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

Regarding the allegation that Staff yell at residents, the following has been concluded: Based on observation and interviews conducted, all parties deny ever directly witnessing or hearing any instances of staff yelling at the clients. As a result, the allegation is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was reviewed and signed by the lead care staff worker. Report was printed before finishing the visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

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