306005335-10-25-2021-22-AS-LADS-CD8RAU-20220406125140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005335
Report Date: 10/22/2021
Date Signed: 10/25/2021 03:17:23 PM

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
04/12/2021 and conducted by Evaluator Shobhana Frank

COMPLAINT CONTROL NUMBER: 22-AS-20210412134613

FACILITY NAME:	DJ GUEST HOME		FACILITY NUMBER:	306005335
ADMINISTRATOR:	BANGGALAT, REGIE		FACILITY TYPE:	740
ADDRESS:	2710 N BERKELEY ST		TELEPHONE:	(657) 224-9328
CITY:	ORANGE	STATE: CA	ZIP CODE:	92865
CAPACITY:	6	CENSUS: 5	DATE:	10/22/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Brevet Dao		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

* Resident developed multiple pressure injuries while in care
* Resident has missing medications
* Facility lacks an adequate food supply
* Staff caused resident physical pain
* Staff do not respond to resident's calls for assistance
* Resident's bathroom is not kept clean
* Staff are not following adequate food service guidelines
* Staff are not safeguarding resident's property

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Shobhana Frank made an unannounced visit to deliver findings on the above allegation. LPA Frank met with Licensee Brevet Dao and explained the reason for the visit.
During the course of the investigation LPA reviewed Physician report dated 11/7/20, St. Joseph hospital report, Admission agreement , interviewed ombudsmen staff, interviewed placement staff, interviewed facility administrator, care staff # 1 and R 1. Investigation in to above allegation is as below.
Investigation in to allegation, Resident developed multiple pressure injuries while in care is unsubstantiated.
During interviews, it was determined that the allegation could not be corroborated by evidence nor witnesses. No physical evidence of multiple pressure injuries to R1. Interviews of R1 and Physicians report and individualized service plan revealed that R1 used to leave in car, she doesn’t have any family, she has stage 4 Cancer and mild cognitive impairment, R 1 had R hip replacement done on 10/6/20 at St. Joseph. Some days she is ok, some days, she is not. Based on interviews of staff R1 walks outside, and when assisted, or accompanied, she is ok. But then tells them not to touch her and claims caregiver hurt her. This is when they assist her to sit on the wheelchair.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 22-AS-20210412134613

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: DJ GUEST HOME	FACILITY NUMBER: 306005335
	VISIT DATE: 10/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

* Resident has missing medications is is unsubstantiated.
R 1 reported that she complaint because she used to take care of her medication and now facility is taking care of her medication.
LPA obtained copies of centrally stored medication records for all residents currently at facility. LPA reviewed medication and observed facility has bubble packs and all medication reflected to be dispensed and logged appropriately.
Staff caused resident physical pain is unsubstantiated.
Based on the observation and review of records reflects facility keeps accurate record of administered medication for all residents in care. Administrator reported that R1 wants to hold her meds, but because we had to lock it on the cabinet, she was not happy about it. Staff tried to please R1 at all times.
Facility lacks an adequate food supply and Staff are not following adequate food service guidelines are unfounded.
LPA visited the facility and facility noted to be clean and in good repaired. LPA observed plenty of fruits and vegetable, available for the residents in care.
LPA observed meal being served. The meal is adequate to meet the nutritional needs of the residents. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. copy of menu and it appears to be a balanced meals. Based on interviews 1 out of 1 (C2) client had no complaints on the quality and/or quantity of food.
Staff do not respond to resident's calls for assistance is unsubstantiated.
During the course of the investigation LPA observed Emergency call buttons Alert system. Based on interviews 1 out of 1 (C2) client had no complaints about Staff do not respond to resident's calls for assistance.

* Resident's bathroom is not kept clean is unsubstantiated.
LPA conducted random inspection of the entire facility which included common bathrooms and bedrooms, living room and kitchen. Hallways and walkways were observed free of debris and clutter. Based on observation, the facility’s bathrooms are clean. The facility appears to be operating in substantial compliance of Title 22 Division 6.
Staff are not safeguarding resident's property is unsubstantiated.
During the course of investigation LPA observed that R 1 bring facility’s can food from kitchen to her room and stored in her closet. R1’s room was clean and her belongings were observed to be in her room.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20210412134613

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: DJ GUEST HOME	FACILITY NUMBER: 306005335
	VISIT DATE: 10/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

Based upon interviews and documentation reviewed investigation on allegations Resident developed multiple pressure injuries while in care, Resident has missing medications, Facility lacks an adequate food supply, Staff caused resident physical pain, Staff do not respond to resident's calls for assistance, Resident's bathroom is not kept clean, Staff are not following adequate food service guidelines, Staff are not safeguarding resident's property, investigation revealed that although the allegation may have happened or is valid, there are no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3