306005475-10-13-2023-22-AS-AORZ-CYNSAX-20231219124303

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005475
Report Date: 10/13/2023
Date Signed: 10/13/2023 04:24:48 PM

Substantiated

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
10/12/2023 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231012154427

FACILITY NAME:	FOUNTAIN VALLEY SENIOR HOMES 2		FACILITY NUMBER:	306005475
ADMINISTRATOR:	ALMIRANEZ, ULDARICO		FACILITY TYPE:	740
ADDRESS:	17690 SAN VICENTE		TELEPHONE:	(949) 290-6006
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	10/13/2023
		UNANNOUNCED	TIME BEGAN:	11:22 AM
MET WITH:	Aida Villanueva, Caregiver and Dolores Martillano, Caregiver		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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-Residents have unsupervised access to cleaning supplies

INVESTIGATION FINDINGS:

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On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz made an unannounced visit to the facility to conduct a 10 day visit to address the allegation listed above. LPA Quiroz was granted entry by Caregiver Aida Villanueva. Ombudsman Linda Bock and Caregiver Dolores Martillano arrived during today's visit. LPA Quiroz called and spoke to L/AD Almiranez during today's visit and discussed purpose of today's visit.
On or about 11:47am, LPA Quiroz along with Caregiver Villanueva commenced the tour of interior and exterior of the facility.
Regarding the allegation, "Residents have unsupervised access to cleaning supplies," the investigation revealed the following: Dring today's inspection visit, on or about 12:18pm, while touring kitchen area along with Caregiver Villanueva and Ombudsman Linda Bock, LPA Quiroz observed unlocker drawer underneath the kitchen sink were Caregiver Villanueva verified disinfectants were stored. LPA Quiroz provided consultation on the following Calfornia Code of Regulation (CCR): Buildings and Grounds: 80087(g)Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.CONTINUED ON NEXT PAGE...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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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Control Number 22-AS-20231012154427

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: FOUNTAIN VALLEY SENIOR HOMES 2	FACILITY NUMBER: 306005475
	VISIT DATE: 10/13/2023

NARRATIVE

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CONTINUED...LPA Quiroz and Ombudsman Linda Bock observed Caregiver Villanueva lock and secure disinfectants indicating "Oh, the staff forgot to lock it in the morning."
Based on the preponderance of evidence gathered through interviews and today's observations;the allegation “Residents have unsupervised access to cleaning supplies” has been met; Therefore, the allegation listed above is deemed to be SUBSTANTIATED.

The facility is being cited per Title 22, Division 6 of the California Code of Regulations. (SEE LIC 9099-D)

An exit interview was conducted with Caregiver Dolores Martillano, and a copy of this report, along with LIC9099-D, Appeal Rights, and the LIC 811-Confidential names were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20231012154427

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: FOUNTAIN VALLEY SENIOR HOMES 2	FACILITY NUMBER: 306005475
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/18/2023 Section Cited CCR 80087(g)	1 2 3 4 5 6 7	Buildings and Grounds: 80087(g)Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement was not met as evidenced by:	1 2 3 4 5 6 7	L/AD Almiranez will provide staff identified on LIC 500 (Personnel Report) training on CCR80087(g) and submit proof of training by 10/18/2023.
	8 9 10 11 12 13 14	on or about 12:18pm, while touring kitchen area along with Caregiver Villanueva and Ombudsman Linda Bock, LPA Quiroz observed unlocker drawer underneath the kitchen sink were Caregiver Villanueva verified disinfectants were stored. CONTINUED...	8 9 10 11 12 13 14	This poses a potential risk to clients in care.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC9099 (FAS) - (06/04)

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