306005393-10-1-2020-22-AS-AORZ-BUJR5G-20201019124303

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005393
Report Date: 09/30/2020
Date Signed: 10/01/2020 08:10:57 AM

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
09/28/2020 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200928112854

FACILITY NAME:	ORANGE COUNTY CARE HOME I		FACILITY NUMBER:	306005393
ADMINISTRATOR:	RASSOULI ZADEHEI, FAHIMEH		FACILITY TYPE:	740
ADDRESS:	23800 HILLHURST DRIVE		TELEPHONE:	(949) 322-1078
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	6	CENSUS: 5	DATE:	09/30/2020
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Fahimeh Rassouli Zadehei		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
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5
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8
9

Staff refused to release resident's records to authorized representative.

INVESTIGATION FINDINGS:

1
2
3
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5
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9
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13

Licensing Program Analyst (LPA) Joseph Alejandre contacted the facility via telephone to commence a complaint investigation via FaceTime due to COVID-19 and precautionary measures. LPA identified himself and discussed the purpose of the call and the elements of the allegation with Administrator (AD) Faith Rassouli.
LPA Alejandre interviewed AD Rassouli. AD Rassouli reported resident 1's (R1) medical records were released to the responsible party of R1. LPA Alejandre interviewed the responsible party for R1. The responsible party reported that after a discussion with the Administrator of the facility the records were provided to the responsible party once they verified their identity. Responsible party stated they had received all of the requested documents.
Therefore the allegation is deemed UNFOUNDED, meaning the allegation is false could not have happened and/or is without a reasonable basis.

This agency has investigated this complaint. An exit interview was conducted with the Administrator via FaceTime and a copy of this report was provided to Administrator via email and an electronic email read receipt confirms receiving these documents.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

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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