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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004532
Report Date: 10/10/2022
Date Signed: 10/10/2022 10:05:27 AM

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
09/21/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220921120152
FACILITY NAME:ASSISTED SENIOR HOMEFACILITY NUMBER:
306004532
ADMINISTRATOR:Z. GLOUNERFACILITY TYPE:
740
ADDRESS:24741 PRISCILLATELEPHONE:
(949) 248-9415
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY:6CENSUS: 5DATE:
10/10/2022
UNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Mary TenorioTIME COMPLETED:
10:23 AM
ALLEGATION(S):
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Staff hit resident resulting in injury.
Staff unable to communicate in English resulting in violation of resident rights
Residents are being bullied by other residents.
Staff are not providing residents with hygiene needs
Residents not being provided dignity and respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry by Caregiver Mary Tenorio and explained the reason for the visit. LPA delivered findings to Licensee via telephone at the facility.

During the course of the investigation, LPA interviewed staff and residents as well as reviewed and obtained pertinent documentation such as staff training. Regarding the allegations that staff hit resident resulting in injury, staff unable to communicate in English resulting in violation of resident rights, residents are being bullied by other residents, staff are not providing residents with hygiene needs and residents not being provided dignity and respect, the investigation revealed the following: LPA interviewed four out of five residents during the investigation. All residents interviewed deny ever being hit by anyone at the facility or being treated with disrespect. Both staff interviewed deny residents have been hit or treated disrespectfully. Resident 1 (R1) denies being pushed or yelled at by R2 and R2 denies such behaviors. Four out of four residents interviewed confirm appropriate toileting and hygiene CONTINUED ON LIC 9099C DATED 10/10/2022
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2022
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-20220921120152
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: ASSISTED SENIOR HOME
FACILITY NUMBER: 306004532
VISIT DATE: 10/10/2022
NARRATIVE
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needs are being met. While Staff 1 (S1) has challenges communicating in English, all residents confirm S1 is great in dealing with the residents and are complimentary towards S1. Interviews with residents indicate no violation of personal rights. Therefore, the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

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

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