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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004363
Report Date: 10/14/2022
Date Signed: 10/14/2022 05:10:14 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
09/23/2021 and conducted by Evaluator Shobhana Frank
COMPLAINT CONTROL NUMBER: 22-AS-20210923083408
FACILITY NAME:ST. FRANCIS HOME FOR THE ELDERLY IIFACILITY NUMBER:
306004363
ADMINISTRATOR:RUNETTE CATIBOGFACILITY TYPE:
740
ADDRESS:11842 FOSTER ROADTELEPHONE:
(562) 637-3392
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY:6CENSUS: 6DATE:
10/14/2022
UNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Administrator Runette CatibogTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff denied visitation to resident's visitor
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Shobhana Frank for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator Runette Catibogand explained the reason for today’s visit.

During the course of investigation LPA Shobhana Frank reviewed COVID Guide Line, conducted interviews at facility with Staff 1 (S1) Staff 2 (S2) Staff 3 (S3) and reporting Party (RP)
Investigation on allegation Staff denied visitation to resident's visitors as below.
LPA obtained and reviewed facility visitation records documenting their visitation plan for all the residents. The timeframe of no face-to-face visitations or no indoor visitation were during the period of restrictions due to COVID-19. Only outdoor visitations as well as virtual visitations were permitted for family members. LPA Shobhana Frank interviewed RP who reported that it was his mistake not fellow COVID guideline. He was regularly visited his mom and facility staff was very cooperative. Staff 1 (S1) stated after he complained he was visiting a lot and he was following COVID Guide line visit outside designated area for the visit of the facility.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
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 2
Control Number 22-AS-20210923083408
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: ST. FRANCIS HOME FOR THE ELDERLY II
FACILITY NUMBER: 306004363
VISIT DATE: 10/14/2022
NARRATIVE
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Based on the information gathered during the investigation interview and review of all documents obtained, the allegation of Staff denied visitation to resident's visitor is Unsubstantiated. Although the allegation had happened or is valid, RP reported that it was his mistake not following COVID guideline, therefore the allegation is Unsubstantiated.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2