306005310-2-10-2023-22-AS-SSAS-CPBVV3-20230223154537

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005310
Report Date: 02/10/2023
Date Signed: 02/10/2023 11:04:16 AM

Substantiated

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
11/10/2022 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221110141619

FACILITY NAME:	QUEEN'S HOME 2		FACILITY NUMBER:	306005310
ADMINISTRATOR:	MAGHBOULEH, KATAYOUN		FACILITY TYPE:	740
ADDRESS:	26545 AVENIDA DESEO		TELEPHONE:	(949) 716-1907
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Arlene Mahinay, Administrator/Caregiver		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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unlawful eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to deliver the findings into the above allegation. LPA was greeted and granted entry by Caregiver Arlene Mahinay who notified Administrator (Admin) Katayoun Maghbouleh of LPA's arrival. Approximately 9:58am, LPA spoke to the Admin by telephone and presented the findings. Adminstrator consented Caregiver Arlene Mahinay to sign the report on her behalf. During the course of the investigation, LPA obtained and reviewed pertinent resident records and conducted interviews with residents, staff, and Administrator. The following are the findings which involved observations, record review, and interviews:

It was alleged that the facility issued an unlawful eviction. Per records reviewed, the family was made aware of Resident 1 (R1) not being an appropriate fit for the facility. The responsible party of R1 was provided a one-week eviction notice by text. Although LPA observed R1 to be living at the facility during the complaint visit, the facility did not comply with the eviction procedures.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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-20221110141619

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 2	FACILITY NUMBER: 306005310
	VISIT DATE: 02/10/2023

NARRATIVE

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Per Title 22 Regulation, 87244 Eviction Procedures, facility is required to issue a formal 30-day eviction notice in writing, therefore the preponderance of evidence standard has been met.

Based on observation, interviews conducted, and the records reviewed, the above allegation is deemed SUBSTANTIATED. A deficiency is being cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See LIC9099D.

An exit interview was conducted with Caregiver Arlene Mahinay, and a copy of this report along with the LIC9099C, LIC811, LIC9099D, and the appeal rights were provided during this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221110141619

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 2	FACILITY NUMBER: 306005310
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/17/2023 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee acknowledges and to issue a 30-day eviction notice and to forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record review and interviews, the licensee did not issue a formal 30-day written notice to ensure a legal eviction which poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

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