306004839-6-2-2021-22-AS-MSTC-C4K34E-20210702175501

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004839
Report Date: 06/02/2021
Date Signed: 06/02/2021 04:49:25 PM

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
03/17/2020 and conducted by Evaluator Lydia Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200317152547

FACILITY NAME:	FULLERTON VILLA		FACILITY NUMBER:	306004839
ADMINISTRATOR:	DARLENE LINDLEY		FACILITY TYPE:	740
ADDRESS:	2441 W. ORANGETHORPE AVE.		TELEPHONE:	(714) 992-5380
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	197	CENSUS: 123	DATE:	06/02/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Darlene Lindley		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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* Lack of supervision resulting in resident threatening another resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lydia Martinez spoke with Administrator Darlene Lindley via telephone due to COVID-19 precautionary measures to discuss the findings on the above allegation. The investigation revealed the following:
The Department received a complaint regarding allegation of lack of supervision resulted in resident threatening another resident. Based on review of Staff schedule, interviews conducted, Unusual Incident report dated 03/07/2020 and review of Fullerton Police Report, Administrator and two (2) Direct Care staff responded to incident between R1 and R2 immediately. R1 and R2 had been roommates for approximately 4 years without any prior incidents other than occasional arguments in which they would resolve and remain friends. Staff responded appropriately by relocating R1 to another room after incident and no further incidents have occurred. Therefore, the allegation is deemed Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Administrator Lindley and a copy of this report along with the 811 was provided via email and an electronic email read receipt confirms receiving these documents. Administrator Lindley agreed to review the report, sign and return a signed copy to LPA Martinez.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

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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