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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005407
Report Date: 02/07/2025
Date Signed: 02/07/2025 01:41:10 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
02/03/2025 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250203140840
FACILITY NAME:MAISON FOR MOMFACILITY NUMBER:
306005407
ADMINISTRATOR:LUDINOT NIC, YAMASHIRO SHEFACILITY TYPE:
740
ADDRESS:804 W BRENTWOOD AVENUETELEPHONE:
(310) 994-9181
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:6CENSUS: 6DATE:
02/07/2025
UNANNOUNCEDTIME BEGAN:
07:07 AM
MET WITH:Licensee Francis MejiaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not provide medication assistance to resident in care
Facility is not kept clean
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 Nicolas Oudinot and Licensee Francis Meija.
During the course of the investigation LPA toured facility, reviewed records, conducted interviews with residents & staff, made observations and requested pertinent documentation such as resident roster, resident appraisal, needs &service plan, and physician’s report.

In regards to allegation “Staff did not provide medication assistance to resident in care”, During investigation LPA Reviewed files, conducted interviews and made observations. LPA reviewed resident records and observed that one of six residents (Resident 1) did not have a Medication Administration record on file. LPA observed that Facility had a medication list for resident 1 but no logs notating when medications are administered. LPA observed R1’s Physician report and Appraisal notated resident is not able to administer own medications and requires assistance with medications. CONTINUED ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
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-20250203140840
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: MAISON FOR MOM
FACILITY NUMBER: 306005407
VISIT DATE: 02/07/2025
NARRATIVE
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Interviews with staff revealed that Staff 1 administers medications to Resident 1 for the day however Staff 1 mentioned that Resident 1 had medications previously in a safe inside bedroom and would give staff approval to assist with meds. Staff1 states they did not have access to medications to create list.

Interview with Resident 1 revealed that staff did not provide medications at proper scheduled time. Interview with Resident 1 revealed that incident regarding assistance with medications happened a couple of times.

During visit LPA observed medications for residents were locked in a secure location and based off medication list Resident 1’s medications were accounted for. Resident 1 had over the counter supplements which did not observe a written physician’s order.

In regards to allegation “Facility is dirty”, LPA observed the following, Facility had cracked floor near bedroom 1, a missing cupboard drawer in kitchen area, and a large hole in Resident 1’s dresser. LPA observed additional clutter and facility items piled up in backyard. Interviews with staff revealed that items located outside are scheduled for trash pick up for later in the month.

Based on records reviewed , observations made and interviews the preponderance of evidence has been met, deeming the allegations staff did not provide medication assistance to resident in care and facility is dirty is deemed SUBSTANTIATED.

The following deficiencies are being cited per Title 22. Licensee Francis Mejia and Administrator Nicolas Oudinot needed to leave during visit and assigned caregiver Joyce Cornejo to sign on their behalf. An exit interview was conducted with caregiver Joyce Cornejo and a copy of this report and appeal rights were provided to facility.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250203140840
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: MAISON FOR MOM
FACILITY NUMBER: 306005407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2025
Section Cited
CCR
87465(a)(6)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(6) When requested by the prescribing physician or
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Licensee to provide inservice training for staff and provide Medication Administration Records for all residents in care. Licensee to provide proof of POC by due date 2/21/25.
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the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by based off record review, facility does not have a Medication Administration Record for one of six residents. This poses a potential health, safety or personal rights risk to persons in care.
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Type B
02/21/2025
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced
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Licensee to address repairs for facility to be in complainace. Licensee has scheduled trash pick up for items in backyard. Licensee to provide proof of POC by due date 2/21/25
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by: Facility has broken drawers, cracked floor and multiple clutter in backyard. This poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3