306004454-6-6-2024-22-AS-AORZ-D67UY9-20240613155932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004454
Report Date: 06/05/2024
Date Signed: 06/06/2024 04:54:21 PM

Unfounded

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
03/11/2024 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240311085256

FACILITY NAME:	NS CARE		FACILITY NUMBER:	306004454
ADMINISTRATOR:	NOVAC SOFRONI		FACILITY TYPE:	740
ADDRESS:	10431 AVENIDA CINCO DE MAYO		TELEPHONE:	(714) 599-3531
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	06/05/2024
		UNANNOUNCED	TIME BEGAN:	03:38 PM
MET WITH:	Novac Sofrani, Licensee/Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Resident sustained an unexplained injury
-Due to lack of supervision resident wandered away

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz, was greeted and met with Novac Sofrani, Licensee/Administrator (L/AD) for the purpose to deliver findings for complaint allegations listed above.
The initial 10-day visit was completed on March 12,2024 by LPA Quiroz.
It was alleged that "Resident sustained an unexplained injury," and that "Due to lack of supervision resident wandered away" as a result of a hospitalization occurring on March 08, 2024. During the course of this investigation, the Department conducted interviews, reviewed documents including but not limited to Resident Roster, Physician Report, Needs and Services Appraisals and emails provided by Licensee including a chronology of events for Resident 1 (R1).
During an inspection dated October 20, 2017, the facility was found to be operating beyond capacity and was cited. At the time, the L/AD Sofrani reported R1 did not require care and supervision. Shortly after the visit, L/AD Sofrani informed the Department R1 had moved out of the facility. During facility inspection visits conducted on March 12, 2024, LPA Quiroz did not observe R1 present at the facility. Six of six residents residing at the facility were not identified to be R1. CONTINUED...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

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-20240311085256

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: NS CARE	FACILITY NUMBER: 306004454
	VISIT DATE: 06/05/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

CONTINIED...Per interview conducted with L/AD Sofrani, he had known R1 and their mother for years and upon moving out of the facility allowed R1 to move into one of his other homes as a renter. L/AD Sofrani denied providing any elements of care and supervision to R1 at that location. Per physician report reviewed dated October 25, 2017, R1 is able to communicate their needs and complete all activities of daily living independently meaning bathing, toileting, managing cash resources and feeding self. R1 is able to leave the facility unassisted per Physician Report.
Although R1 was hospitalized, the investigation concluded that R1 does not reside at NS Care Facility and that L/AD Novac Sofrani is not providing care for R1.
Therefore based on the preponderance of evidence gathered through interviews and observations conducted by LPA Quiroz, the allegation that the "Resident sustained an unexplained injury," and that "Due to lack of supervision resident wandered away" is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint.
No deficiencies cited during today's visit.
An exit interview was conducted with L/AD Sofrani and a copy of report was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2