306004826-8-8-2024-22-AS-LMOA-D8M2YM-20240829174858

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004826
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:08:50 PM

Unsubstantiated

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
07/31/2024 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240731162025

FACILITY NAME:	ORANGEWOOD GUEST HOME		FACILITY NUMBER:	306004826
ADMINISTRATOR:	MEL CARBAJAL MIN FAJARDO		FACILITY TYPE:	740
ADDRESS:	1598 W. ORANGEWOOD AVE.		TELEPHONE:	(714) 583-8965
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY:	6	CENSUS: 4	DATE:	08/08/2024
		UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Melissa Carbajal		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Resident was hit by a facility staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to investigation a complaint received July 31, 2024. LPA Haley was greeted by staff and explained the reason for the visit before entering the facility. The complaint investigation consisted of interviews with facility staff, residents, witnesses, and document review.

Regarding the allegation: Resident was hit by a facility staff.

5 of 8 individuals interviewed denied the complaint allegation above. During interview with multiple individuals, it was revealed Resident 1 (R1) has a history making false statements and having emotional outburst. Staff 1 (S1) explained R1 has outburst at the day program and has had outburst with the bus driver as well. S1 provided progress notes for R1 that document several of R1’s outburst. During an interview with Resident 2 (R2), the resident explained they get along with R1, and mentioned R1 yells and screams sometimes.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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-20240731162025

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: ORANGEWOOD GUEST HOME	FACILITY NUMBER: 306004826
	VISIT DATE: 08/08/2024

NARRATIVE

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During an interview with Witness 1 (W1) it was revealed R1's behaviors are well documented and W1 has had discussions with the facility as well as R1's day program regarding these behaviors. A review of R1’s Individualized Program Plan (IPP) dated January 11, 2024, list challenging behaviors for R1 including disruptive social behavior, self-injurious behavior, emotional outburst, and special conditions or behaviors that include assaultive behaviors that could have resulted in serious bodily injury or death.

Based on the information gathered during the investigation through interviews, 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, the allegation is deemed Unsubstantiated.

An exit interview was conducted, and a copy of this report was provided..

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC9099 (FAS) - (06/04)

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