306004761-12-28-2023-22-AS-AORZ-CYYRG9-20231229120022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004761
Report Date: 12/28/2023
Date Signed: 12/28/2023 11:30:26 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
10/08/2020 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201008113606

FACILITY NAME:	CAMBRIDGE COURT		FACILITY NUMBER:	306004761
ADMINISTRATOR:	LAUREN CHON		FACILITY TYPE:	740
ADDRESS:	1621 COMMONWEALTH AVENUE, EAST		TELEPHONE:	(714) 992-1750
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92831
CAPACITY:	99	CENSUS: 76	DATE:	12/28/2023
		UNANNOUNCED	TIME BEGAN:	08:32 AM
MET WITH:	Daniela Lopez-Receptionist, Melissa Reyes-Medication Technician		TIME COMPLETED:	11:44 AM

ALLEGATION(S):

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Facility is not following the admission agreement in regards to smoking at the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings of the investigation. LPA was greeted and granted entry into the facility by Receptionist Daniela Lopez. LPA explained the reason for the visit.

This agency has investigated the complaint alleging that facility is not following the admission agreement in regards to smoking at the facility. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: One of six individuals interviewed confirmed the allegation. During interviews conducted with the residents, Resident 1 (R1) reported that this was supposed to be a non-smoking facility and that their Admission Agreement states that. Per R2 residents who smoke always smoke at the table in the central courtyard. During the course of the investigation LPA reviewed documents including the Admission Agreement dated 02/07/15 for R1. Per Admission Agreement on page 7 under House Rules/Facility Policies it states that the following behaviors are not consider
CONTINUED ON LIC9099-C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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-20201008113606

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: CAMBRIDGE COURT	FACILITY NUMBER: 306004761
	VISIT DATE: 12/28/2023

NARRATIVE

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appropriate for residents residing at our facility: smoking in the facility. During the course of the interviews ED stated that smoking is allowed in the designated smoking area. Per ED as of 08/10/21 there were new additional smoking rules that were suggested by the resident council. Records reviewed by LPA included the Cambridge Court Smoking Rules dated 08/10/21. Per Smoking Rules all smoking should be done in the designated smoking area and only in the designated smoking area.

Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: facility is not following the admission agreement in regards to smoking at the facility is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with Medication Technician Reyes, and a copy of this report, 9099-D Page, and Appeal Rights was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20201008113606

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: CAMBRIDGE COURT	FACILITY NUMBER: 306004761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/04/2024 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement... This regulation was not met as evidenced by: Based on interviews conducted and file reviews the facility failed to follow their non-smoking policy	1 2 3 4 5 6 7	Licensee/Administrator agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	as documented per facility's Admission Agreement. This poses a potential risk to resident’s health and safety while in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC9099 (FAS) - (06/04)

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