306005475-2-27-2024-22-AS-AORZ-D2VSX9-20240228131535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005475
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:11:55 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
04/13/2023 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230413150926

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: 5	DATE:	02/27/2024
		UNANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Dolores Martillano, Caregiver and Uldarico Almiranez, Licensee/Administrator		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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-Resident was verbally abused by staff

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 4/19/2023. On today's date, LPA Quiroz arrived to the facility and was greeted by Caregiver 1 (CG1). LPA Quiroz called Licensee/Administrator (L/AD) Uldarico Almiranez and discussed purpose of today's visit via telephone. (L/AD) Almiranez arrived during today's visit.
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), Resident Roster and anonymous videos provided to the department.
Regarding the allegation “Resident was verbally abused by staff," the investigation revealed the following: LPA Quiroz conducted multiple interviews with interviewees consisting of residents, staff and other witnesses. An anonymous video was received by the department on 10/11/2023. (CG1) verified audion voice on video recording indicating "Yes, that was me. I'm so sorry but I was very tired and we were short staffed." This is an amended report***

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: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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-20230413150926

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: 02/27/2024

NARRATIVE

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CONTINUED... LPA was able to confirm the violation pertained to Resident 1 (R1) in care.

Based on the preponderance of evidence gathered through interviews and today's observations; the allegation “Resident was verbally abused by staff” has been met; Therefore, the allegation listed above is deemed to be SUBSTANTIATED.

LPA Quiroz provided consultation on California Code of Regulations (CCR) 80072(a)(1)(2)(3): Personal Rights. The facility is being cited per Title 22, Division 6 of the (CCR). (SEE LIC 9099-D)

An exit interview was conducted with facility staff, 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: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230413150926

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: 02/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/01/2024 Section Cited CCR 80072(a)(1)(2)(3)	1 2 3 4 5 6 7	80072(a)(1)(2)(3) each client shall have personal rights which include, but are not limited to, the following:(1)To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe...This requirement is not being met as evidenced by:CONTINUED BELOW...	1 2 3 4 5 6 7	(L/AD) agreed to conduct personal rights training to staff and provide proof & updated LIC 500. (L/AD) will submit sign in sheet for training and updated LIC 500 by POC due date of 3/1/24. (L/AD) advised LPA the facilty has hired 1:1 staff for R1 to be able to meet R1s needs according to N&S plan.
	8 9 10 11 12 13 14	CONT(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including CONT... An anonymous video was received by the department on 10/11/2023. (CG1) verified audion on video recording indicating "Yes, that was me. I'm so sorry but I was very tired and we were short staffed."LPA was able to confirm the violation pertained to Resident 1 (R1) in care. CONTINUED...	8 9 10 11 12 13 14	CONT...eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This poses a potential health and safety risk to residents in care.
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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: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

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