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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005195
Report Date: 12/21/2022
Date Signed: 12/21/2022 04:05:58 PM

Substantiated


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
12/15/2022 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221215121856
FACILITY NAME:EMBASSY RESIDENTIAL CARE IIFACILITY NUMBER:
306005195
ADMINISTRATOR:KON, CORAFACILITY TYPE:
735
ADDRESS:1621 E SANTA ANA STREETTELEPHONE:
(714) 732-7217
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:6CENSUS: 5DATE:
12/21/2022
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Gloria AvilesTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Resident left at facility without staff supervision.
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Staff #1 (S1) Gloria Aviles, discussed the purpose of the inspection, and explained the allegation. Administrator (AD) Cora Kon appeared via telephone. The investigation into the allegation of Resident left at facility without staff supervision revealed the following: During the course of the investigation, LPA interviewed AD, 1 staff, 1 witness, and 5 residents, and requested and reviewed copies of the resident roster, staff roster, and staff timesheets.

It was reported that residents were recently at the facility with only 1 staff, S1, who was off duty present. LPA interviewed S1 who stated that on that particular day there were other staff who left to take two residents to a doctor’s appointment, that S1 was supposed to be off that day but covered a gap of approximately one and a half hours as the only staff at the facility with 3 residents present, but that S1 provided care and supervision to the residents as usual despite being off duty. It was reported that during this time period S1 refused to help a resident make food and stated they were off duty.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
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 3
Control Number 22-AS-20221215121856
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: EMBASSY RESIDENTIAL CARE II
FACILITY NUMBER: 306005195
VISIT DATE: 12/21/2022
NARRATIVE
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S1 denied this and stated that there was already food for this particular resident, but this resident wanted a different type of food and the facility does not have the kitchen appliance necessary to make the requested food item. LPA conducted health and safety checks on 5 residents and observed no health and safety issues. LPA interviewed 5 residents who denied that they are ever left at the facility with no staff present. However, LPA reviewed S1’s timesheet for the day of the incident which states that it was a day off for S1, that S1 was not claiming time worked for that day, and that S1 will not be paid for covering the one and half hour gap. While S1 may have been present, S1 was not on duty and was not paid for their time and the allegation is substantiated.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties in the amount of $500 are being assessed. Civil penalties of $100 per day, per violation will accrue until the deficiencies are corrected. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20221215121856
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: EMBASSY RESIDENTIAL CARE II
FACILITY NUMBER: 306005195
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2022
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee stated it was an isolated incident. Licensee agreed to review the timesheet with S1 to ensure S1 claims time worked, to create a procedure for similar situations, and to submit proof to LPA by 1/11/23.

CIVIL PENALTY ASSESSED
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Based on interviews and documents, the licensee did not ensure 3 residents received care and supervision from an on-duty staff for about one and half hours, which poses an immediate safety and personal rights risk to residents 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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3