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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004555
Report Date: 11/05/2020
Date Signed: 11/05/2020 04:56:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CAPRIANAFACILITY NUMBER:
306004555
ADMINISTRATOR:TONYA REYNOLDSFACILITY TYPE:
741
ADDRESS:460 LA FLORESTA DRTELEPHONE:
(714) 589-2866
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:200CENSUS: 140DATE:
11/05/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Tonya ReynoldsTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre conducted a case management visit regarding complaint 22-AS-20200506084825. Due to Covid-19 pre-cautionary measures LPA Joseph Alejandre contacted the facility via telephone to conduct the visit. LPA identified himself and discussed the purpose of the call with Administrator (AD) Tonya Reynolds. On May 06, 2020, a complaint (#22-AS-20200506084825) was received by the Orange County Adult and Senior Care Program regarding the allegation that Facility did not protect resident from financial abuse. The complaint was investigated by the Department. During this investigation, interviews were conducted with staff, witnesses and records were obtained and reviewed. The investigation uncovered other issues concerning the facility that were not part of the complaint allegation. The investigation revealed that Staff 1 (S1) was not associated to the facility. The facility did not complete a background transfer request for S1. The facility did not provide basic services to Resident 1 (R1) as described in their plan of operation. R1 was removed from the facility by S1 and R1 was not properly signed in and out, the facility was unaware of R1 leaving the facility in this manner until the complaint was filed. Once the complaint had been filed the facility did not use their theft and loss policy as required by the Health and Safety Code and investigate the possible theft reported by R1's family and did not report the incident to law enforcement. The complaint investigation revealed that even though the administrator is responsible for the facility, the administrator did not run the facility in accordance with these regulations and established policy, program and budget. Based on the information revealed during the complaint investigation, the following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations and the Health and Safety Code. An exit interview was conducted with the Administrator and a copy of this report was provided via email along with appeal rights. Administrator Tonya Reynolds agreed to review, sign and return the report. Electronic email receipt confirms receipt of all documents. The report will be kept in the facility file.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CAPRIANA
FACILITY NUMBER: 306004555
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2020
Section Cited

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criminal record clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:(2)Request a transfer of a criminal record clearance as specified in Section 87355(c). This
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requirement is not being met as evidenced by S(1) who has a background clearance was not associated to the facility. This poses an immediate Health and Safety Risk to residents in care.
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Type A
11/06/2020
Section Cited

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Basic service requirements - Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not being met as evidenced by; R1 was removed and then returned from the facility by S1 without permission and signing out R1.
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The facility administrator and support staff were unaware that R1 had been removed and returned to the facility. This poses an immediate Health and Safety Risk to residents 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) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CAPRIANA
FACILITY NUMBER: 306004555
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2020
Section Cited

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administrator-Qualifications and Duties - (h) The administrator shall have the responsibility to: (1) Administer the facility in accordance with these regulations and established policy, program and budget. This requirement is not being met as evidenced by
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The administrator/facility was unaware that R1 had been removed from the facility, did not follow the theft/loss policy and was unaware that S1 was not associated to the facility, this poses an immediate Health and Safety Risk to the residents in care.
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Type A
11/06/2020
Section Cited

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Safeguard of resident property reimbursement for failure to make reasonable efforts; preseumption; penalty(a) A residential care facility for the elderly, as defined in Section 1569.2, which fails to make reasonable efforts to safeguard resident property shall reimburse a resident for or replace stolen or lost resident property at its then current value.
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This requirement is not being met as evidenced by, The facility did not investigate the possible theft reported by R1's family member. This poses an immediate Health and Safety Risk to residents 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) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CAPRIANA
FACILITY NUMBER: 306004555
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2020
Section Cited

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Theft and loss program; standards, property inventories and surrender of personal effects; secured areas - Reports to the local law enforcement agency within 36 hours when the administrator of the facility has reason to believe resident property with a then current value of one hundred dollars ($ 100) or more has been stolen... This requirement,
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is not being met as evidenced by; once the facility was informed about the possible theft they did not notify law enforcement. This poses an immediate Health and Safety Risk to clients 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) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4