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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005428
Report Date: 10/06/2021
Date Signed: 10/06/2021 10:46:22 AM

Unsubstantiated


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
03/06/2020 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200306094700
FACILITY NAME:DIGNITY & WISDOM IIFACILITY NUMBER:
306005428
ADMINISTRATOR:TESFAY, SABAFACILITY TYPE:
740
ADDRESS:2330 CAMINO ESCONDIDOTELEPHONE:
(714) 871-1464
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 5DATE:
10/06/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Saba Tesfay, AdministratorTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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-Facility staff left residents unsupervised
INVESTIGATION FINDINGS:
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This announced visit conducted by Licensing Program Analysts (LPAs) Ruth Martinez and Beverly Thompson-Gracia is being conducted to conclude this agency’s investigation into the above mentioned complaint allegation. LPAs arrived at the facility was greeted and granted entry by caregiver. LPA met with Saba Tesfay, Administrator and explained the nature of today’s visit.

Findings are based upon this investigation which included file reviews and interviews. It is alleged that facility staff left resident unsupervised. LPA Martinez and LPA August conducted a visit on 03/20/2020 at 7:30pm and observed two caregivers onsite. Interviews conducted revealed that 3 out of 5 residents indicated that there is always staff at night and if they need assistance during the night a caregiver always comes to assist them.


Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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 2
Control Number 22-AS-20200306094700
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: DIGNITY & WISDOM II
FACILITY NUMBER: 306005428
VISIT DATE: 10/06/2021
NARRATIVE
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Interview conducted with Administrator revealed that there are two live in staff. File review revealed that there are two caregivers during the hours of 7:00pm to 7:00am, Monday - Sunday.

Based on the information gathered during the investigation 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.

A copy of this report is being reviewed with Administrator and a copy of this LIC9099 furnished to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2