306005475-11-2-2023-22-AS-AORZ-CZZTLB-20240131134915

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005475
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:44:46 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
10/10/2023 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231010115905

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:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Uldarico Almiranez, Licensee/Administrator via telephone, Rome Peleno and Crispina Gayados, Caregiver.		TIME COMPLETED:	03:44 PM

ALLEGATION(S):

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-Facility staff is not able to meet resident's needs

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose of concluding and delivering findings to address the allegation listed above. The 10-day visit complaint investigation was conducted by LPA Quiroz on 10/12/2023. On today's date, LPA Quiroz arrived to the facility and was greeted by Caregiver Joselyn Arcelo and met with Caregiver Crispina Gayados and Rome Peleno. LPA Quiroz called Licensee/Administrator (L/AD) Uldarico Almiranez and discussed purpose of today's visit via telephone.
During the course of the investigation the following documents were reviewed but not limited to: Physician reports, identification forms, needs and services plans, LIC 500 (Personnel Report) and Resident Roster.
Regarding the allegation “Facility staff is not able to meet resident's needs," the investigation revealed the following: LPA Quiroz conducted multiple interviews with interviewees consisting of residents, staff and other witnesses. Interviews conducted with twelve of thirteen Interviewees denied the allegation. Resident 1 (R1) indicated “No not true. Not true. The staff here are wonderful and take very good care of me and everyone else.” CONTINUED...

Unfounded

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: 10/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2023

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-20231010115905

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: 11/02/2023

NARRATIVE

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CONTINUED... (R1)s responsible party indicated "(R1) will often call 911 themselves prior to addressing concerns with staff."
Interview conducted with (R1) revealed (R1) reported on unknown date calling 911 without notifying staff indicating "I know I should have told staff first but I called myself." LPA Quiroz reviewed Special Incident Report dated 7/20/2023 indicating (R1) calling 911 on or about 10:30pm, (R1) was picked up by paramedics on or about 10:40pm and returned to the facility on 7/21/2023 or about 12:15am with no new orders and/or new diagnose.
Seven of seven staff interviewed indicated facility has sufficient amount of staff working in the facility indicating (R1) to have their own assigned caregiver and rehabilitation worker to facilitate being able to meet all resident’s needs and requests timely as requested by all residents in care.
Based on the evidence gathered through interviews conducted, facility observations and a review of pertinent documentation, the allegation: " Facility staff is not able to meet resident's needs” is deemed Unfounded, meaning that the allegations is false, could not have happened and/or is without a reasonable basis; Therefore complaint allegation is dismissed.

An exit interview was conducted with Licensee/Administrator Uldarico Almiranez via telephone and with Caregiver Rome Peleno at the facility. A copy of this report along with LIC 811- Confidential Names list were provided to Facility at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2023

LIC9099 (FAS) - (06/04)

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