306004376-6-13-2022-22-AS-MVAO-CG4TFS-20220707144200

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004376
Report Date: 06/13/2022
Date Signed: 06/13/2022 03:55:19 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
05/25/2021 and conducted by Evaluator Patricia Velazquez

COMPLAINT CONTROL NUMBER: 22-AS-20210525085006

FACILITY NAME:	IRVINE CARE HOME		FACILITY NUMBER:	306004376
ADMINISTRATOR:	CRISTINA EVANGELISTA		FACILITY TYPE:	740
ADDRESS:	41 BETHANY		TELEPHONE:	(949) 861-3178
CITY:	IRVINE	STATE: CA	ZIP CODE:	92603
CAPACITY:	6	CENSUS: 4	DATE:	06/13/2022
		UNANNOUNCED	TIME BEGAN:	01:53 PM
MET WITH:	Cristina Evangelista - Administrator		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff is denying resident's authorized representative a refund

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to investigate the above allegation. LPA Velazquez was allowed entry into the facility and met with Caregivers Milani and Jose Villasis. LPA spoke with Administrator Cristina Evangelista on the phone and explained the purpose of the visit.

On today's visit LPA Velazquez reviewed facility and resident records. LPA was provided with copies of pertinent documentation in Resident (R) #1's file. LPA Velazquez also conducted interviews with staff. During the course of the investigation LPA reviewed facility and resident records. LPA also conducted interviews with the complainant and facility staff. The records reviewed included the resident roster, staff schedule, admissions agreement, physician's report, durable power of attorney documents, resident appraisal needs and services plan, doctor's report/medical log, and death report. LPA was also provided a copy of a Bank of

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

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-20210525085006

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: IRVINE CARE HOME	FACILITY NUMBER: 306004376
	VISIT DATE: 06/13/2022

NARRATIVE

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the West bank statement for May 1, 2021 - May 31, 2021 reflecting check number 2847 in the amount of $6349.94 paid by the bank on May 24, 2021 which Administrator Evangelista indicated was the amount refunded to the family of R1 upon R1's death. Per Administrator Evangelista the check was written on May 13, 2021 and Administrator also provided LPA with a copy of the canceled check. Administrator Evangelista also provided copies of email communication between R1's DPOA and the Administrator. The individuals interviewed provided conflicting statements regarding the above allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the following allegation: Staff is denying resident's authorized representative a refund is deemed UNSUBSTANTIATED. An exit interview was conducted with Caregiver Milani Villasis and a copy of this report along with the LIC 811s were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

LIC9099 (FAS) - (06/04)

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