306005385-1-26-2024-22-AS-SSAS-CZZ22N-20240130160100

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005385
Report Date: 01/26/2024
Date Signed: 01/26/2024 05:10:23 PM

Substantiated

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
11/06/2023 and conducted by Evaluator Kevin Saborit-Guasch

COMPLAINT CONTROL NUMBER: 22-AS-20231106143648

FACILITY NAME:	ORANGE COUNTY CARE HOME II		FACILITY NUMBER:	306005385
ADMINISTRATOR:	RASSOULI ZADEHEI, FAHIMEH		FACILITY TYPE:	740
ADDRESS:	27561 ALMENDRA DRIVE		TELEPHONE:	(949) 322-1078
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	01/26/2024
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Johnny Bugton, caregiver		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not ensure adequate care and supervision was provided to resident in care

Staff do not ensure adequate incontinence care is provided to resident in care

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted and granted entry by facility caregivers after explaning the purpose of the visit. Administrator Faith Rassouli was unavailable due to a medical emergency. Report was reviewed with caregiving staff.

An initial complaint investigation visit was conducted on November 15, 2023. LPA conducted a review of records for resident R1 kept at the facility as well as interviews with administrator and one present staff members were additionally conducted in addition to a tour of the physical plant. A follow-up investigation visit was held on January 18, 2024. During the visit, it was determined that R1 no longer resided at the facility. An additional staff interview was conducted then. A collateral visit for the purpose of attempting to interview the alleged victim took place on January 26, 2024 at another licensed facility.

CONTINUED ON FORM LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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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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
11/06/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231106143648

FACILITY NAME:	ORANGE COUNTY CARE HOME II		FACILITY NUMBER:	306005385
ADMINISTRATOR:	RASSOULI ZADEHEI, FAHIMEH		FACILITY TYPE:	740
ADDRESS:	27561 ALMENDRA DRIVE		TELEPHONE:	(949) 322-1078
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	01/26/2024
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Johnny Bugton, caregiver		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 22-AS-20231106143648

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: ORANGE COUNTY CARE HOME II	FACILITY NUMBER: 306005385
	VISIT DATE: 01/26/2024

NARRATIVE

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CONTINUED FROM FORM LIC9099-A
Regarding the allegation of an Illegal Eviction, the following has been concluded: Based on records reviewed and interviews conducted, a 30-notice to vacate served by the facility administrator was found to fulfil the regulatory requirements of Title 22 regulations by licensing staff. However, it was also determined that resident R1 was not evicted, but voluntarily moved to a more adequate facility with the assistance of a care coordinated agency. No eviction actually took place. As a result, the allegation is found to be Unfounded, meaning that meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 7

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
11/06/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231106143648

FACILITY NAME:	ORANGE COUNTY CARE HOME II		FACILITY NUMBER:	306005385
ADMINISTRATOR:	RASSOULI ZADEHEI, FAHIMEH		FACILITY TYPE:	740
ADDRESS:	27561 ALMENDRA DRIVE		TELEPHONE:	(949) 322-1078
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	01/26/2024
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Johnny Bugton, caregiver		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff do not ensure resident is kept in clean dry clothing at all times.

Staff handled resident in a rough manner

Staff did not safeguard residents personal property

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 22-AS-20231106143648

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: ORANGE COUNTY CARE HOME II	FACILITY NUMBER: 306005385
	VISIT DATE: 01/26/2024

NARRATIVE

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CONTINUED FROM FORM LIC9099-A
Regarding the allegation that Staff do not ensure resident is kept in clean dry clothing at all times, the following has been concluded: The allegation is identical to the allegation that Staff do not ensure adequate incontinence care is provided to resident in care which was Substantiated and for which a type A citation was issued. In order not to cite the facility twice for the same deficiency, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

Regarding the allegation that Staff handled resident in a rough manner, the following has been concluded: Based on interviews conducted, multiple statements regarding potential rough handling of resident R1 by a facility former staff member were made. However, multiple contradictory statements were also made and no injury was evidence. There is therefore insufficient evidence to prove that the incident did occur, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

Regarding the allegation that Staff did not safeguard residents personal property, the following has been concluded: Several personal items belonging to R1 were reported as missing such as cosmetic products. Records reviewed indicated that the items in question had not been placed under the facility's safeguarding responsibility inventoried upon admission. Additionally, multiple lost items were later found in the resident's bedroom, and safeguarding solutions in the form of a lockbox were put into place. As a result, there is insufficient evidence to indicate that the facility was deficient, The allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 22-AS-20231106143648

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: ORANGE COUNTY CARE HOME II	FACILITY NUMBER: 306005385
	VISIT DATE: 01/26/2024

NARRATIVE

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CONTINUED FROM FORM LIC9099
Regarding the allegation that Staff do not ensure adequate incontinence care is provided to resident in care, the following has been concluded: Based on interviews conducted and records reviewed, the facility does not provide routine care between the hours of 10pm and 6:30am, with the exception of non-routine, urgent needs being noted. It was however determined that it was a routine occurrence for facility staff to try to prevent R1's incontinence issues with the simultaneous use of multiple diapers at once rather than proceed to routine diapers changes throughout the night. Facility staff admitted to the practice which was also reported by hospital staff upon the resident's admission to the emergency department. The occurrence of a urinary tract infection can also be related to the practice. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type A citation is issued in regard to the deficiency.

Regarding the allegation that Staff did not ensure adequate care and supervision was provided to resident in care, the following has been concluded: Based on staff interviews, it was determined that after notifying a resident's responsible party that the facility was no longer suited to address the resident's need for nightly assistance, no modification to the resident's actually delivered care were made, thus not adequately meeting the resident's needs at the time. The allegation is therefore found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type A citation is issued in regard to the deficiency.

An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20231106143648

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: ORANGE COUNTY CARE HOME II	FACILITY NUMBER: 306005385
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/27/2024 Section Cited CCR 87625(b)(2)	1 2 3 4 5 6 7	CCR Section 87625(b)(2) on Managed Incontinence states that "(...) the licensee shall be responsible for (...) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night". This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to provide statement that updated policies and training will be conducted regarding nightly care for incontinent residents.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, facility staff had adopted the practice of stacking diapers at night rather than conduct routine checks. This poses an immediate risk to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14
Type A 01/27/2024 Section Cited HSC 1569.2(c)	1 2 3 4 5 6 7	Per the Health & Safety Code: "(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, or welfare would be endangered. (...)	1 2 3 4 5 6 7	Licensee to provide statement that updated policies and training will be conducted regarding nightly care for incontinent residents.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews conducted, no routine checks of the resident's hygiene were implented after it became evident that nightly incontinence was present. This poses an immediate to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14

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) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

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