306005229-11-8-2023-22-AS-MSTC-CYB5KV-20231207190206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005229
Report Date: 11/08/2023
Date Signed: 11/08/2023 12:29:08 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
10/15/2020 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201015155838

FACILITY NAME:	EL CINCO FAMILY HOME CARE		FACILITY NUMBER:	306005229
ADMINISTRATOR:	CINCO, EMMYLOU		FACILITY TYPE:	735
ADDRESS:	24892 STEM AVE		TELEPHONE:	(949) 716-9467
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 4	DATE:	11/08/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Emmylou Cinco		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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-Staff member denied client ability to communicate with friends, family, day program, and participate in Zoom activities

-Staff member failed to return client's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrive at facility was greeted by caregiver and granted entry. LPA spoke with Emmylou Cinco, A and explained the purpose of the visit.

Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegations. Findings are based upon this investigation which include interview and copy of pertinent documents obtained. It is alleged that staff member denied client ability to communicate with friends, family, day program, and participate in Zoom activities. The individual interviewed provided conflicting statements that could not corroborate to the above allegations. Interviews with staff (S1) did not give indications that client (C1) is not given the ability to communicate with others and there are no indications

Continued on LIC809-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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-20201015155838

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: EL CINCO FAMILY HOME CARE	FACILITY NUMBER: 306005229
	VISIT DATE: 11/08/2023

NARRATIVE

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that the facility staff were in possession of C1’s personal belongings. Interviews and record review revealed that when the State of California was place in an order to stay home facility staff provided clients with facility telephone, desktop computer, tablets and/or cellphones. S1 had other alternatives for clients to make phone calls and/or Zoom meeting with day programs. Facility clients used the facility desktop computer, facility house phone and or staff personal cell phone for facetime calls as needed. Record review revealed that since there was a state of emergency and clients were not attending community activities C1 became more interested in physical activity at the facility rather than using time on the electronics.

It is alleged that staff member failed to return client’s personal belongings. S1 indicated the lack of communication between staff and clients did not allow C1 to realize that their personal belongings were in C1’s bedroom nightstand drawer. On March 19, 2020, the stay at home order became active and S1 obtained permission from C1’s responsible party to put away electronics due to recent elopement behaviors that occurred every Friday. S1 created a new goal for C1 to aid in C1’s health and wellness with consent of responsible party. On March 20, 2020, S1 purchased a new exercise machine for C1 to aid with physical activity. Records revealed that the implementation of the new goal made an improvement with C1’s behavior episodes. S1 stated that C1 showed more interest in physical activities rather than using electronics to occupy C1’s time. Based on the information received from interviews, records review, and the lack of corroborating witnesses, LPA is unable to determine if the alleged violations occurred as reported.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with Administrator and a copy of this LIC9099 report was left at facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC9099 (FAS) - (06/04)

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