306005260-5-29-2024-22-AS-LMOA-D5SRQN-20240531131349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005260
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:52:52 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
08/03/2021 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-NP-20210803071759

FACILITY NAME:	COAST SENIOR CARE		FACILITY NUMBER:	306005260
ADMINISTRATOR:	VIANA, KRISTEN		FACILITY TYPE:	740
ADDRESS:	22201 CAPE MAY LANE		TELEPHONE:	(714) 377-0638
CITY:	HUNTINGTON BEACH	STATE:	ZIP CODE:	92646
CAPACITY:	0	CENSUS: 5	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Mitzi Avena- Caregiver		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff hit resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Jessica Cho and Jenifer Tirre made an unannounced collateral visit to Coast Senior Care 1 which is their new location located at 19861 Carmania Lane, Huntington Beach, California 92646. The purpose of the today's visit is to continue the investigation and deliver the findings into the above allegation. LPAs were allowed entry and explained the reason for the visit to Caregiver Reynoldo Avena. LPA Tirre made contact with Administrator (Admin) Kristen Viana by telephone approximately 9:50am and was advised of the visit. On August 5, 2021, LPA Jenifer Tirre initiated the complaint investigation which consisted of a tour, interviews with two staff and four residents, and obtained documentation pertaining to Resident #1 (R1). On today's date, LPAs toured the physical plant and observed five residents and two caregivers on duty. LPAs interviewed five residents, two caregivers, and requested copies of the following pertinent documentation: Resident Roster, Face Sheets, and Physician's Reports for all residents. The investigation revealed the following:

[Continued on LIC9099-C...]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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-NP-20210803071759

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: COAST SENIOR CARE	FACILITY NUMBER: 306005260
	VISIT DATE: 05/29/2024

NARRATIVE

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It is alleged that the facility staff hit the resident in care. Based on the interviews, seven out of the eight residents and three out of the three staff denied the allegation. Seven residents denied being inappropriately touched or hit and stated that they are treated well by the caregivers. Witness interview revealed that R1 also recanted the allegation. R1 did not divulge information about the abuse during the interview, and no other information was provided related to the abuse.

Therefore, based on the observations made, interviews which were conducted, and the records that were reviewed, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Facility staff hit resident in care is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Kristen Viana by telephone, signed by Caregiver Mitzi Avena, and a copy of this report including the LIC9099-C and the LIC811 were provided to the facility representative at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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