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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005195
Report Date: 12/22/2023
Date Signed: 12/22/2023 03:17:20 PM

Unsubstantiated


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
08/05/2022 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220805130952
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:
12/22/2023
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Gloria AvilesTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Facility staff yells at client.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced complaint investigation for the purpose of delivering findings regarding the allegation mentioned above. LPA met with Staff Gloria Aviles and explained the purpose of the inspection.

Interviews were conducted with AD, facility Staff 1 (S1) alleged to have yelled at client, an additional care Staff 2 (S2), and five clients. S1 denied they yell and stated their “voice is just loud naturally.” AD and S2 also denied witnessing staff yelling at client. During interviews, Client 1 (C1) confirmed staff yell and stated yelling consisted of shouting “hey, hey, hey!”, when he attempted to put food in the fridge. Two out of four additional clients interviewed denied staff yell, and two clients were unable to confirm or deny allegation.

Due to conflicting information received during interviews conducted, LPA is unable to determine if staff yells at client. (Cont. LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
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 2
Control Number 22-AS-20220805130952
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: 12/22/2023
NARRATIVE
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Although the above 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 at this time the above allegation is unsubstantiated.

An exit interview was conducted with Staff Aviles and copy of this report was provided at the end of the inspection.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2