306004700-12-7-2023-22-AS-SSAS-CYGS9A-20231213124023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004700
Report Date: 12/07/2023
Date Signed: 12/07/2023 10:31:08 AM

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
11/01/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231101095717

FACILITY NAME:	QUALITY SENIOR LIVING HOUSE #2		FACILITY NUMBER:	306004700
ADMINISTRATOR:	MARIA DOLORES D. TENTE		FACILITY TYPE:	740
ADDRESS:	26791 MORENA DRIVE		TELEPHONE:	(949) 309-9314
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Maria Dolores- Administrator		TIME COMPLETED:	10:31 AM

ALLEGATION(S):

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Staff abandoned resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced and met with Administrator (Admin) Maria Dolores who arrived at 10:25am for the purpose of delivering the findings into the above allegation. LPA explained the reason for the visit and reviewed the allegation with the Administrator.

On November 7, 2023, LPA initiated the 10-day complaint investigation and interviewed staff. LPA did not obtain copies of Resident #1 (R1) records as the original records were released to R1's hospital. A subsequent visit was made on November 28, 2023, and additional interviews were attempted. The following was revealed during the course of the investigation:

It is alleged that the staff abandoned the resident. Per interviews conducted with three out of the three staff, R1 is independent, alert, and oriented. R1 left the facility on October 31, 2023, for a doctor’s appointment. Three out of the three staff stated during the interviews that R1 had expressed an interest in leaving the facility due to allegedly having parasites in their body.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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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Control Number 22-AS-20231101095717

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: QUALITY SENIOR LIVING HOUSE #2	FACILITY NUMBER: 306004700
	VISIT DATE: 12/07/2023

NARRATIVE

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Due to conflicting information obtained during the interviews, there was insufficient evidence to corroborate the allegation.

Therefore, based on the interviews which were conducted, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Staff abandoned resident is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Maria Dolores, and a copy of this report including the LIC811 were provided at the end of the visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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