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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004514
Report Date: 04/11/2023
Date Signed: 04/11/2023 03:27:15 PM

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
04/04/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230404105310
FACILITY NAME:NORTHWOOD CARE HOMEFACILITY NUMBER:
306004514
ADMINISTRATOR:TERESA ALPUERTOFACILITY TYPE:
740
ADDRESS:7 BRAGGTELEPHONE:
(949) 653-5742
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: 5DATE:
04/11/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Teresa Alpuerto - AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility illegally evicted resident.
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Danilo De Guzman, House Manager and explained the reason for the visit. Administrator Teresa Alpuerto arrived at 9:20am with Francis Mallari, Manager.

The department received a complaint on 04/04/2023 and the initial 10 day visit was conducted on 4/11/2023. During the course of the investigation LPA reviewed document such as Individual Program Plan (IPP), house rules and admission agreements. LPA Mendivil also interviewed staff and residents. Regarding the allegation facility illegally evicted resident, the investigation revealed the following:

Based on interviews and incident report received on 3/14/2023, it was reported that Resident 1 (R1) was physically aggressive towards staff. 911 was called and resident was transported to the hospital. CONT on LIC 9099-C dated 4/11/2023.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
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 5
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
04/04/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230404105310

FACILITY NAME:NORTHWOOD CARE HOMEFACILITY NUMBER:
306004514
ADMINISTRATOR:TERESA ALPUERTOFACILITY TYPE:
740
ADDRESS:7 BRAGGTELEPHONE:
(949) 653-5742
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY:6CENSUS: 5DATE:
04/11/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Teresa Alpuerto - AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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9
Facility did not provide a safe environment for residents
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by House Manager Danilo De Guzman. Administrator Teresa Alpuerto and Francis Mallari arrived shortly after.

During the course of the investigation LPA reviewed document such as Individual Program Plan (IPP), house rules and admission agreements. LPA Mendivil also interviewed staff and residents. Regarding the allegation facility did not provide a safe environment for residents, the investigation revealed the following:

Based on interviews with 2 out of 5 residents indicated they felt safe at the facility. Interviews with 2 out of 5 residents reported they did not feel threatened at the facility and believe they are well taken care of. 3 of the residents were unable to be interviewed as one resident refused to be interviewed and the 2 other residents are not able to respond. Interviews with 4 out of 4 staff indicate they did their best in keeping the residents staff and comfortable and safe.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20230404105310
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: NORTHWOOD CARE HOME
FACILITY NUMBER: 306004514
VISIT DATE: 04/11/2023
NARRATIVE
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Therefore based on the preponderance of evidence through interviews the allegation facility did not provide a safe environment for residents is UNSUBSTANTIATED, meaning, that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint.
No deficiencies cited.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20230404105310
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: NORTHWOOD CARE HOME
FACILITY NUMBER: 306004514
VISIT DATE: 04/11/2023
NARRATIVE
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Based on interviews with Administrators Francis Mallari and Teresa Alpuerto it was reported that facility staff refused to work if R1 returned to the facility after their hospital stay. Based on interviews with Administrators R1 was not provided an eviction notice and the department was not notified of facility's intent to evict resident.

Therefore based on preponderance of evidence through interviews the allegation that facility illegally evicted resident is SUBSTANTIATED, meaning the complaint allegation was valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.


SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230404105310
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: NORTHWOOD CARE HOME
FACILITY NUMBER: 306004514
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2023
Section Cited
HSC
1569.682(2)
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The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person.
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Licensee to update eviction procedures and provide to LPA by POC due date.
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This was not met as evidence by facility denied entry to a resident after discharge from hospital, which poses a potential risk to persons 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: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5