306005374-5-22-2024-22-AS-LMOA-D692SQ-20240614173930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005374
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:35:13 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
05/14/2024 and conducted by Evaluator Jenifer Tirre

COMPLAINT CONTROL NUMBER: 22-AS-20240514164855

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: 6	DATE:	05/22/2024
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Administrator Shahin Mokhtarzad		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff are not available to assist residents at night

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation into the above allegations. LPA explained the reason for the visit with Administrator Shahin Mokhtarzad

During the course of the investigation LPA toured facility, reviewed records, conducted interviews, made visual observations and requested pertinent documentation such as Resident Roster, Admission Agreements, staff trainings, Functional Capability Assessment and Physician’s reports.
During investigation LPA reviewed facility records such as Personnel records, training, and resident records. Records reviewed revealed that Personnel files of staff had training in importance & techniques of personal care, Dementia training in RCFE, Resident Rights, and Direct care staff orientation. Three of three staff obtained CPR Certification and Background clearance.

CONTINUED ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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-AS-20240514164855

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: EVER CARE	FACILITY NUMBER: 306005374
	VISIT DATE: 05/22/2024

NARRATIVE

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. Resident records revealed that six of six residents had resident and or responsible parties signed Admission agreements that included a section regarding Overnight staff which states “ Overnight wake staff is provided at Ever Care when prescribed by a physician, requested by resident or responsible person or when determined by the facility that additional level of care is needed. An additional charge will be assessed by Facility when overnight wake staff is provided.”

Interviews conducted revealed the following: three of three staff confirm all residents have a operating call system to which residents can push when needing assistance. Staff interviewed stated they respond to resident call system. Three of three staff stated that during the middle of the night when go to bathroom they conduct resident rounds. Two of three residents interviewed indicated there have been a couple of incidents where either staff did not respond immediately or not at all. Three of three residents interviewed confirmed that facility has staff present at all times and are never left unattended inside facility. All three residents interviewed indicated staff try their best to provide good care.

During investigation, LPA pressed alert system buttons to confirm alerts are operational and loud. LPA observed when pressing alert buttons staff responded immediately.

Based on records reviewed, interviews conducted, and observations made although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the following allegations: staff are not available to assist residents at night is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator and a copy of this report was reviewed and provided at the time of this visit.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC9099 (FAS) - (06/04)

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