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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005205
Report Date: 10/07/2022
Date Signed: 12/08/2022 10:03:57 AM

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
12/02/2021 and conducted by Evaluator Shobhana Frank
COMPLAINT CONTROL NUMBER: 22-AS-20211202082646
FACILITY NAME:NOUMEA CARE HOME IIFACILITY NUMBER:
306005205
ADMINISTRATOR:CONSOLACION BURGOSFACILITY TYPE:
735
ADDRESS:5978 NOUMEA STREETTELEPHONE:
(714) 686-1289
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:6CENSUS: 5DATE:
10/07/2022
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Care staff Karen Saturno TIME COMPLETED:
03:49 PM
ALLEGATION(S):
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Clients personal rights were violated.
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Shobhana Frank for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Care staff Karen Saturno and explained the reason for today’s visit. On 12/1/2021 The Orange County Adult & Senior Care Program Regional Office received four Special Incident Reports (SIR) from the Regional Center of Orange County (RCOC). All four reports contained the same information. The SIR reports that during an unannounced inspection at Noumea Care Home II, full and unopened beer bottles in the patio area near the BBQ grill were observed.

During the investigation LPA Frank toured inside/outside of the facility, interviewed the staff and clients. Based on the facility inspection LPA Frank did not observe any beer bottles inside the facility or outside the storage area. Interviews were conducted with clients whom denied drinking any beer or observing anyone drinking beer. Interviews were conducted with staff whom denied drinking any beer or observing anyone drinking beer. S1 reported that staff was cleaning outside storage and one empty bottle of beer

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
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 2
Control Number 22-AS-20211202082646
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: NOUMEA CARE HOME II
FACILITY NUMBER: 306005205
VISIT DATE: 10/07/2022
NARRATIVE
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was found from the storage and the bottle was in the patio area along with the trash. S1 did not know who drank the beer and also denied if any clients had drink the beer.

Based on the information gathered through observation and interviews there was not a preponderance of evidence to prove or disprove that Clients personal rights were violated. Therefore, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.An exit interview was conducted with facility representative and a copy of this report provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2