306005475-2-27-2024-22-AS-AORZ-D2W27Q-20240228160905

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005475
Report Date: 11/02/2023
Date Signed: 02/27/2024 03:49:07 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
06/21/2022 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220621095243

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:	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	02:02 PM
MET WITH:	Uldarico Almiranez, Licensee/Administrator		TIME COMPLETED:	02:36 PM

ALLEGATION(S):

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-Resident's medication is not being administered as prescribed
-Resident is not being assisted in a timely manner
-Facility failed to provide a safe enviornment

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 allegations listed above. The 10 day visit complaint investigation was conducted on 6/27/2022. 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 documentes were reviewed but not limited to: Physician reports, identification forms, needs and services plans, LIC 500 (Personnel Report), Resident Roster and Medication Training Records.
Regarding the allegation, "Resident's medication is not being administered as prescribed," the investigation revealed the following: Twelve of thirteen interviewees consisting of residents, staff and other witnesses indicated medications are being administered as prescribed. Twelve of thirteen interviewees indicated Caregiver 1 (C1) is the assigned staff member CONTINUED...***This is an amended report***

Unsubstantiated

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-20220621095243

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...assigned to administer medications to the residents in care. During facility inspection visits conducted on 6/27/2022, 10/12/2023 and 10/13/2023, LPA Quiroz observed (C1) to be holding the key to the medication closet area and observed (C1) to administer medications to residents in care. LPA Quiroz reviewed medication training records which revealed (C1) has received medication training.
Regarding the allegation, "Resident is not being assisted in a timely manner," the investigation revealed the following: Twelve of thirteen interviewees consisting of staff, residents and other witnesses indicated staff respond to call light buttons in a timely manner. L/AD Almiranez indicated that the needs in this facility were demanding; therefore L/AD Almiranez hired a designated caregiver and two rehabilitation workers for Resident 1 (R1) and Resident (R2) to allow facility staff sufficient amount of staff to meet all the residents in care needs.
Regarding the allegation, "Facility failed to provide a safe environment," the investigation revealed the following: Twelve of thirteen interviewees consisting of staff, residents and other witnesses indicated feeling safe and not fearing for their safety. L/AD Almiranez indicated "I have assigned staff who work well with specific residents. Certain residents have preferences in staff and the assignments are working well for everyone."
Based on the evidence gathered through interviews conducted, facility observations and a review of pertinent documentation, the allegations:"Resident's medication is not being administered as prescribed," "Resident is not being assisted in a timely manner," and "Facility failed to provide a safe environment" are deemed Unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis; Therefore complaint allegations are 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.

***This is an amended report***

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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