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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004759
Report Date: 09/20/2024
Date Signed: 09/20/2024 10:44:07 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
09/10/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240910152630
FACILITY NAME:TLC ELDERLY RESIDENCE 1FACILITY NUMBER:
306004759
ADMINISTRATOR:TALLAT BATLAFACILITY TYPE:
740
ADDRESS:25751 GOLDEN ROD CIRCLETELEPHONE:
(949) 367-9248
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:5CENSUS: 5DATE:
09/20/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Masroor Batla- AdministratorTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Licensee is refusing to provide copy of admission agreement to responsible person.
Licensee is refusing to provide copy of billing statement to responsible person.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced subsequent visit for the purpose of delivering the findings into the above allegations. LPA was greeted and granted entry and explained the reason of the visit to Administrator (Admin) Masroor Batla. On September 17, 2024, LPAs Jessica Cho and Edward Kim initiated the complaint investigation and interviewed five residents and three staff. Pertinent records of Resident #1 (R1) were obtained during the visit which includes the Face Sheet, Identification and Emergency Information, Physician's Report, Admission Agreement, Notice of Termination, billing invoices paid on October 2022, and all correspondence receipts with R1's responsible person as well as the current residents' Roster, Personnel Report, Face Sheets, and Physician's Reports. Additional interviews and records of former residents were obtained on September 18, 2024.

The investigation revealed the following: It is alleged that the licensee is refusing to provide copy of admission agreement and the billing statement to the responsible person.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
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 5
Control Number 22-AS-20240910152630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TLC ELDERLY RESIDENCE 1
FACILITY NUMBER: 306004759
VISIT DATE: 09/20/2024
NARRATIVE
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Based on the review of records, R1 resided at the facility for 26 days from October 6, 2022 to October 31, 2022. On Tuesday, September 7, 2024, at 12:28pm, R1's Responsible Person (RP) requested a copy of the admission agreement and billing invoice for the month of October 2022. A follow-up text was sent by the RP on Tuesday, September 10, 2024 at 8:38am indicating that the copy of R1's admission agreement and billing statement was not provided. Administrator Batla responded at 11:00am that the admission records were provided to the RP to take home to sign (which had allegedly taken two weeks to complete and return). Admin requested time to search for the records as they were in storage. Per review of the email receipts, the admission agreement and the billing invoice was submitted to the RP via email on Sunday, September 15, 2024 at 2:51pm. Per Title 22 Regulation, Additional Personal Rights of Residents in Privately Operated Facilities, 87468.2, records are provided promptly within two business days, however it took the Administrator nine days to produce the records requested.

Therefore, based on LPA's interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations, Licensee is refusing to provide copy of the admission agreement to responsible person and Licensee is refusing to provide copy of billing statement to responsible person, are deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. A deficiency is being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator Masroor Batla, and a copy of this report and the appeal rights were provided at the end of the visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
09/10/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240910152630

FACILITY NAME:TLC ELDERLY RESIDENCE 1FACILITY NUMBER:
306004759
ADMINISTRATOR:TALLAT BATLAFACILITY TYPE:
740
ADDRESS:25751 GOLDEN ROD CIRCLETELEPHONE:
(949) 367-9248
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:5CENSUS: 5DATE:
09/20/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Masroor Batla- AdministratorTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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9
Caregivers hit residents.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced subsequent visit for the purpose of delivering the findings into the above allegations. LPA was greeted and granted entry and explained the reason of the visit to Administrator (Admin) Masroor Batla. On September 17, 2024, LPAs Jessica Cho and Edward Kim initiated the complaint investigation and interviewed five residents and three staff. Pertinent records of Resident #1 (R1) were obtained during the visit which includes the Face Sheet, Identification and Emergency Information, Physician's Report, Admission Agreement, Notice of Termination, billing invoices paid on October 2022, and all correspondence receipts with R1's responsible person as well as the current residents' Roster, Personnel Report, Face Sheets, and Physician's Reports. Additional interviews and records of former residents were obtained on September 18, 2024.

The investigation revealed the following: It is alleged that the caregivers hit the residents. Per interviews conducted, three out of three staff and three out of five residents did not corrroborate the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20240910152630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: TLC ELDERLY RESIDENCE 1
FACILITY NUMBER: 306004759
VISIT DATE: 09/20/2024
NARRATIVE
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The two remaining resident interviews were not obtained due to a language barrier and refusal. Three out of three individuals also interviewed also denied the allegation.

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

An exit interview was conducted with Administrator Masroor Batla, and a copy of this report was provided at the end of the visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240910152630
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TLC ELDERLY RESIDENCE 1
FACILITY NUMBER: 306004759
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/27/2024
Section Cited
CCR
87468.2(a)(19)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, ...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records… and…shall be provided within two (2) business days…This requirement was not met as evidenced by:
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Records were provided to the family on September 15, 2024. Adminstrator stated that he will submit an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.
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Based on interviews and review of records, the administrator provided the records nine days later which poses a potential Personal Rights risk to persons 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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5