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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004684
Report Date: 07/26/2022
Date Signed: 07/26/2022 02:41:14 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
06/29/2022 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220629090846
FACILITY NAME:EL CINCO HOME CAREFACILITY NUMBER:
306004684
ADMINISTRATOR:EMMYLOU CINCOFACILITY TYPE:
735
ADDRESS:25151 COSTEAU STREETTELEPHONE:
(949) 305-3821
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: DATE:
07/26/2022
UNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Emmlou CincoTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Administrator interfering with reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrive at facility was greeted by caregiver and granted entry. LPA spoke with Emmylou and explained the purpose of the visit.

Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which include interviews with staff, clients and witness. The individuals interviewed provided conflicting statements that could not corroborate to the above allegation. Interviews with clients, witness and staff did not give indications that there are concerns in regard to keeping everyone informed. Records review included a chronology of notices to day programs for client. Records also revealed that the last day the Administrator was at the facility was on 06/21/2022.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
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-20220629090846
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: EL CINCO HOME CARE
FACILITY NUMBER: 306004684
VISIT DATE: 07/26/2022
NARRATIVE
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Records indicated that the Department received required reporting on 06/22/2021. Based on the information received from interviews, the lack of information regarding interference with reporting, and the lack of corroborating witnesses, LPA is unable to determine if the alleged violation occurred as reported.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with Administrator and a copy of this LIC9099 report was left at facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2