306005309-12-16-2021-22-AS-LADS-CGQUL7-20220727154014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005309
Report Date: 12/16/2021
Date Signed: 12/16/2021 12:40:50 PM

Unfounded

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
12/07/2021 and conducted by Evaluator Albert Marin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20211207154544

FACILITY NAME:	QUEEN'S HOME I		FACILITY NUMBER:	306005309
ADMINISTRATOR:	MAGHBOULEH, KATAYOUN		FACILITY TYPE:	740
ADDRESS:	24422 ZANDRA DRIVE		TELEPHONE:	(949) 716-1835
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	12/16/2021
		UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Administrator Katayoun Maghbouleh		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Resident's hygiene needs are not being met.
Resident is over-medicated.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to initiate the investigation for the complaint filed against this facility. LPA met with Administrator (AD) Katayoun "Kathy" Maghbouleh; and stated the purpose of this visit and the allegations indicated above.

LPA Marin did a tour of the interior and exterior portions of the facility, which included the all five resident’s rooms and common areas. After the tour, LPA conducted random interviews and file review.

On the allegation that the resident's hygiene needs are not being met, the following are the findings. Based on observation, file review and interviews, all the residents in the facility require incontinent care. During the visit, LPA observed resident's beds were made and in order. LPA did not observe any offending odors nor soaked hygiene items left in resident’s rooms. Facility had adequate supply of hygiene products. Per random interviews of witnesses, all denied having concerns or issues on facility not meeting resident’s hygiene needs. Thus, the allegation is unfounded.
Continuation in Page 2

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

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-20211207154544

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: QUEEN'S HOME I	FACILITY NUMBER: 306005309
	VISIT DATE: 12/16/2021

NARRATIVE

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On allegation that the resident is over medicated, the following are the findings. Per physician’s report issued last November 23, 2021, Resident 1 has the primary diagnosis of age-related physical disability. Resident was determined not able to care for all personal needs. On November 26, 2021, Resident was admitted under hospice with terminal diagnosis of Alzheimer’s Disease. Resident is currently prescribed with antipsychotic, antidepressant, pain medications as needed for pain and a sedative as needed for agitation. Per file review, all medications were given as ordered by the physician. During the visit, LPA observed the resident to be awake. Thus, the allegation is unfounded.

This agency has investigated the complaint alleging that the resident's hygiene needs are not being met; and that the resident is over-medicated. We have found that the complaint allegations were unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

LPA Marin conducted an exit interview with AD Kathy Magbouleh; and copy of this report was left in the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

LIC9099 (FAS) - (06/04)

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