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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004576
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:31:01 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
03/22/2021 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210322122108
FACILITY NAME:COLUMNS CARE HOMEFACILITY NUMBER:
306004576
ADMINISTRATOR:LOUIS C. GARCIAFACILITY TYPE:
740
ADDRESS:17332 LAURIE LANETELEPHONE:
(714) 884-4083
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:6CENSUS: 4DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Louis GarciaTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Licensee installed safety doorknobs to prevent resident from leaving personal room and facility.
Facility does not have adequate night time supervision.
Facility is not in good repair
Perimeter gates are locked

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to deliver the findings of this complaint investigation. Upon arrival, LPA met with Louis Garcia.

On 3/25/21 at approximately 12:50pm, LPA toured the facility inside and out via facetime with Staff Raul Pagcaliwagen. During the tour LPA noted a slide lock at the top of the front door as well as a key lock above the door handle that locked from the inside. Resident #3 had a child safety doorknob on his bedroom door which would prevent R3 from exiting the room. The grout in the master bedroom was observed to be very dirty and needed to be regrouted in several places, especially around the toilet. Administrator Louis Garcia arrived at approximately 1:03pm and LPA toured the facility with him via facetime. The facility gates were not locked at the time of tour. Mr. Garcia did admit to LPA that he had bought a lock per the caregiver requests.






Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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 4
Control Number 22-AS-20210322122108
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: COLUMNS CARE HOME
FACILITY NUMBER: 306004576
VISIT DATE: 11/29/2022
NARRATIVE
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Records were reviewed and interviews were conducted. The LIC500 (Personnel Report) and interviews with staff and Administrator disclosed that staff work 7 days a week and that there are no awake night staff.

Resident #1, #2 and #3's records were reviewed as they had a Dementia diagnosis. Resident #1, #2 had wandering tendencies and according to staff did wander.

Based upon interviews, LPA's observations and a review of records, the preponderance of evidence standard has been met and the allegations are substantiated.

See LIC9099D for cited deficiencies.

An exit interview was conducted with and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20210322122108
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: COLUMNS CARE HOME
FACILITY NUMBER: 306004576
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2022
Section Cited
CCR
87468.1(a)(6)
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Personal Rights of Residents in All Facilities-Residents shall have the following personal right: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.
This requirement was not met as evidenced by:
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On 3/25/21, the locks were removed and certification was provided via email. On today's date, 11/29/22 LPA did not observe any locks.
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On 3/25/21 LPA observed a slide lock at the top of the front door as well as a key lock above the door handle that locked from the inside. Resident #3 had a child safety doorknob on his bedroom door which would prevent R3 from exiting the room.

This posed an immediate personal rights risk.
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Type B
12/02/2022
Section Cited
CCR
87705(4)(a)
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Care of Persons with Dementia-Licensees who accept and retain residents with dementia shall be responsible for an adequate number of direct care staff. In a facility with fewer than 16 residents at least one night staff person should be awake and on duty if any resident with dementia is determined to require awake night supervision.


This requirement was not met as evidenced by:
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Licensee understands that the facility is a 24 hour facility and that if a resident wanders, there should be awake staff present to meet that residents needs. Proof of understanding will be provided.
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This requirement was not met as evidenced by: R1 and R2 had Dementia and wandering tendencies and there was no staff awake.

This posed a potential health and safety risk to residents in 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: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20210322122108
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: COLUMNS CARE HOME
FACILITY NUMBER: 306004576
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2022
Section Cited
CCR
87303(a)(1)
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Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement was not met as evidenced by:
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Administrator stated that the tile in the master bedroom needs to be replaced. He stated that he ensures it is kept clean. Certification will be provided regarding the plan for upkeep of the master bedroom bathroom.
On today's date LPA noted the bathroom had been grouted and cleaned and the toilet was sealed with caulking around the bottom.
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On 3/25/21 LPA observed the grout in the master bedroom to be very dirty and needed to be regrouted in several places, especially around the toilet.

This posed a potential health and safety risk to residents in care.

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Type B
11/29/2022
Section Cited
CCR
87705(l)(2)
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Care of Persons with Dementia-The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement was not met as evidenced by:
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Administrator understands that the side gates cannot be locked unless approved by the fire department for locked perimeters. Proof of understanding will be provided.

Gates were not locked on today's date.
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The gates at the facility were locked and the Licensee's fire clearance does not approve locked perimeters. While the gates were not locked at the time of the 3/25/21 visit, Administrator admitted to LPA that he had bought locks at the caregivers request. This posed a potential personal rights 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: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4