306005508-11-15-2022-22-AS-LADS-CMTQ8F-20230106105637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005508
Report Date: 11/15/2022
Date Signed: 11/15/2022 01:52:19 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
11/09/2022 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221109102211

FACILITY NAME:	LOMITA GUEST HOME		FACILITY NUMBER:	306005508
ADMINISTRATOR:	DAO, BREVET		FACILITY TYPE:	740
ADDRESS:	1919 E LOMITA AVE		TELEPHONE:	(714) 602-6414
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 3	DATE:	11/15/2022
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Brevet Dao		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility failed to take care of residents needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannouced visit regarding the complaint allegation listed above. LPA Haley was greeted and granted entry by staff. LPA Haley met with Administrator (AD) Brevet Dao and explained the reason for the visit.

LPA Haley interviewed AD Dao, Staff 1 (S1), Staff 2 (S2), Resident 2 (R2), Resident 3 (R3), and attempted to interview Resident 1 (R1) regarding the complaint allegation. AD Dao, emailed LPA Haley copies of the Physicans report, Appraisal Needs & Service Plan, Pre-placement appraisal, and emergency contact information for R1, R2, and R3.

Regarding the allegation above, the investigation revealed the following: during the initial complaint visit LPA Haley interviewed AD Brevet, staff and residents. During the visit LPA Haley observed a Home Health Aid from Care Dimensions Health Care taking care of R2. Further, R2 receives Physical Therapy (PT) once a week and they usually come to see the resident on Monday's.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

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-20221109102211

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: LOMITA GUEST HOME	FACILITY NUMBER: 306005508
	VISIT DATE: 11/15/2022

NARRATIVE

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Further, the interview with AD Dao revealed a Home Health Aid from Fortitude Hospice Inc comes to see R3 Monday, Wednesday, and Friday. Kaiser comes to see R1 as needed or requested by staff, Kaiser also calls to check on R1. During the visit residents were observed in their rooms eating and watching TV.

Regarding the allegation above, based on the information gathered during the investigation, review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with Administrator Dao and a copy of this report and LIC811 was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC9099 (FAS) - (06/04)

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