306004609-6-13-2022-22-AS-SSAS-CFLVHF-20220621162703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004609
Report Date: 06/13/2022
Date Signed: 06/13/2022 03:31:31 PM

Unsubstantiated

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
02/18/2022 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220218164544

FACILITY NAME:	SOMERSET HOME 3		FACILITY NUMBER:	306004609
ADMINISTRATOR:	LENETTE L. BELEN		FACILITY TYPE:	735
ADDRESS:	1735 W. FERN DRIVE		TELEPHONE:	(714) 814-8149
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	6	CENSUS:	DATE:	06/13/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Lenette Belen		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Medical attention is not being sought for resident while in care.
Laundry services are not adequate
Resident is being spoken to inappropriately by staff
Resident was being denied use of their phone
Resident's personal possessions are not safeguarded.
Resident's funds are not being provided to resident while in care
Staff are not using designated smoking area
Resident is being served food that they are allergic to

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to issue the complaint findings for the above allegations. Upon arrival, LPA met with.Lenette Belen. The investigation consisted of interviews with Staff, Client #1, Administrator, and witnesses as well as documentation from the facility. The following was determined: Client #1(C1) was admitted into the facility on May 2, 2014. C1 has a Conservator and is a Regional Center Client. According to C1’s Medical Assessment and Individual Program Plan (IPP) C1 is able to communicate and can occasionally become confused. She needs staff assistance with instructions and all her personal needs. Staff supervise C1 when she leaves the facility and provide assistance with C1’s Personal and Incidental money.

Based upon interviews and records reviewed, the allegations are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator Lenette Belen.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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