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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005471
Report Date: 03/02/2022
Date Signed: 03/02/2022 03:43:44 PM

Unfounded


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
02/25/2022 and conducted by Evaluator Kathrina Chin
COMPLAINT CONTROL NUMBER: 22-AS-20220225094508
FACILITY NAME:A&M ASSISTED LIVINGFACILITY NUMBER:
306005471
ADMINISTRATOR:NATALIA SURGENTFACILITY TYPE:
740
ADDRESS:4461 PALOMA LANETELEPHONE:
(714) 366-1858
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 6DATE:
03/02/2022
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Daniela Usurelu, Caregiver & Kevin Surgent, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared adults living at the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts(LPAs), Kathrina Chin and Jessica Cho made an unannounced visit to investigate a complaint. LPA also met with the caregiver (staff 1) and Kevin Surgent Administrator and discussed the above allegation.

The investigation into the allegation that uncleared adults living at the facility revealed the following:

LPAs conducted an interview with the caregiver and Administrator. Mr. Surgent reported that staff 1 and her adult son (staff 2) are both live-in caregivers. LPAs observed that both employees have fingerprint clearances and have complete staff records on file. LPA's interviewed two residents and both indicated only staff 1 and staff 2 are live-in caregivers. Both reported that they have not seen other adults reside at the facility. Staff 3 is a live-out caregiver but was not working at the time of the visit. (Continued on LIC 9099C).
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
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-20220225094508
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: A&M ASSISTED LIVING
FACILITY NUMBER: 306005471
VISIT DATE: 03/02/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on the above findings, this allegation is determined to be UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted, appeal rights explained, and a copy of this report was given to Kevin Surgent, Administrator.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2