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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005206
Report Date: 10/05/2021
Date Signed: 10/05/2021 10:03:17 AM



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
04/05/2021 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210405142621
FACILITY NAME:SOCAL ASSISTED LIVINGFACILITY NUMBER:
306005206
ADMINISTRATOR:CHENG, CHIN-WENFACILITY TYPE:
740
ADDRESS:8132 STERLING DRIVETELEPHONE:
(714) 267-4105
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 5DATE:
10/05/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Megan ChengTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff handled resident in a rough manner causing bruising.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jenifer Tirre met with Administrator Megan Cheng to discuss the purpose of the visit and go over the findings for the above allegations.

The investigation consisted of staff, resident and family interviews as well as facility documentation. The investigation also consisted of obtained Police and Medical records. Regarding the allegation Staff handled resident in a rough manner causing bruising, the investigation revealed through medical records, observations and family confirmation that resident has thin skin and a history of bruising easily. Police report revealed that officer was unable to determine if resident’s injury was intentionally caused by staff. Investigation also revealed that Emergency Services Injury report stated x-rays showed no fractures caused. Investigation also revealed that appraisal states that resident hallucinates and has had a brain injury previously causing resident to become forgetful. Interviews with residents revealed that 5 out of 5 residents like the care provided and have no issues with the staff members of Socal Assisted Living.
CONTINUED ON LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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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Control Number 22-AS-20210405142621
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: SOCAL ASSISTED LIVING
FACILITY NUMBER: 306005206
VISIT DATE: 10/05/2021
NARRATIVE
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Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Administrator Cheng and a copy of report was left at facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2