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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005462
Report Date: 10/21/2022
Date Signed: 11/29/2022 03:48:28 PM

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
09/01/2020 and conducted by Evaluator Shobhana Frank
COMPLAINT CONTROL NUMBER: 22-AS-20200901092141
FACILITY NAME:EASTERSEALS SOUTHERN CALIFORNIA-CLARISSA RESIDENCEFACILITY NUMBER:
306005462
ADMINISTRATOR:ARMANDO FLORESFACILITY TYPE:
735
ADDRESS:14361 CLARISSA LANETELEPHONE:
(714) 526-4079
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:4CENSUS: 2DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Administrator Armando FloresTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Client not given medication as prescribed
Client tested positive for amphetamines
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shobhana Frank made an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry by Administrator (AD) Armando Flores and explained the reason for the visit.
During the course of investigation LPA Shobhana Frank conducted interview with RP, Staff 1 (S1) Staff 2 (S2) and reviewed Medication Administration Record (MAR) dated 8/2020 of medications administered, Doctor’s Order dated 7/21/2020, Staff Training log dated 11/2020, LIC 500 Personnel Report, Special Incident Report dated 8/25/2020.
Based on interview of S1, C1 tested positive for amphetamines but hospital never provided copy of results; therefore, the facility does not have a document or proof stating C1 was positive for amphetamines. Client never came back to the facility from the hospital. The pharmacist also reported that C1 was prescribed Klonopin 2mg 3 times per day, which if taken as prescribed could have produced a positive result for amphetamines. Due to conflicting information received during interviews, and Medication Administration
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
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-20200901092141
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: EASTERSEALS SOUTHERN CALIFORNIA-CLARISSA RESIDENCE
FACILITY NUMBER: 306005462
VISIT DATE: 10/21/2022
NARRATIVE
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obtained, LPA is unable to corroborate the allegations. Therefore, the Client not given medication as prescribed and Client tested positive for amphetamines allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.
An exit interview was conducted with Administrator and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2