306005374-7-22-2021-22-AS-AORZ-C5S2LH-20210810172931

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005374
Report Date: 07/22/2021
Date Signed: 07/22/2021 01:15:03 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
08/21/2020 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200821162502

FACILITY NAME:	EVER CARE		FACILITY NUMBER:	306005374
ADMINISTRATOR:	MOKHTARZAD, SHAHIN		FACILITY TYPE:	740
ADDRESS:	24985 HENDON ST		TELEPHONE:	(949) 616-4785
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS: 0	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	11:57 AM
MET WITH:	Shahin Mokhtarzad, Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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-Facility staff caused multiple fractures to resident while in care

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 allegation. LPA arrive at facility was greeted at the door by Administrator and granted entry. LPA met with Administrator and explained the nature of the visit.

The investigation was conducted by the Department. Findings are based upon this investigation which included file review, interviews and medical records.

The Department received an allegation that facility staff caused multiple fractures to resident while in care. The investigation did not produce substantial evidence to support an allegation of physical abuse to Resident #1 (R1). Interviews conducted with OC Sheriff Department, Laguna Hills Health and rehabilitation Center

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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-20200821162502

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: EVER CARE	FACILITY NUMBER: 306005374
	VISIT DATE: 07/22/2021

NARRATIVE

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Staff, and 2 of 2 facility staff reveled that R1 appeared unfocused and very confused. The allegation was also investigated by Orange County Sheriff’s Department, who conducted interviews including with R1. R1 state a large man, about 6’3” abused them and called them a dog. R1 further stated the man would come into the room at night and hit them. R1 also described the 6’3” man as white, with short black curly hair, and approximately 30 years old. OC sheriff officer conducted interviews with facility staff and found no one that matched the description given. Orange County Sheriff’s Department closed the case with no pursuance of criminal prosecution and found no evidence of abuse. Case related medical records were obtained for R1. Medical records revealed that R1 had a left clavicle and partial rib fracture, however witnesses interviewed stated this was known and possibly from a fall sustained earlier in the month. No evidence was found in the medical records obtained that supported an allegation occurred as reported. Furthermore, medical records did not document or notate suspected injuries occurred due to abuse. Interview with staff reveled that when R1 was placed in the facility, R1’s diagnosis was known and was reported to be a “night owl”. R1 would get very emotional and often uncooperative when receiving services.

Based on the information gathered during the investigation, interviews and review of all documents obtained, 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 LIC-9099 report was left at facility.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

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