<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005534
Report Date: 09/16/2022
Date Signed: 09/27/2022 10:15:23 AM

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
01/13/2022 and conducted by Evaluator Shobhana Frank
COMPLAINT CONTROL NUMBER: 22-AS-20220113165052
FACILITY NAME:COMFORT KEEPERS HOME CAREFACILITY NUMBER:
306005534
ADMINISTRATOR:MITRICA, CONSTANTIN EMILFACILITY TYPE:
740
ADDRESS:928 ORANGEWOOD DRTELEPHONE:
(714) 800-9249
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 6DATE:
09/16/2022
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Licensee Constantin MitricaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff left resident unattended
Facility staff over medicated resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Shobhana Frank for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with License Constantin Mitrica and explained the reason for today’s visit.
During the course of investigation LPA Shobhana Frank conducted interview at facility with Licensee/Administrator,facility staff) S 1, S 2,S 3, S 4, (Hospice staff) S 5, S 6 and RP. Also reviewed facility Medication Administration Medication Record (MAR) LIC 601 Identification and emergency information, LIC 602 physicians report. medication log, LIC 603 preplacement appraisal Information, Facility staff schedule LIC 500, from August 2021 to January 2022, Notes from RP, Admission Agreement, Emanate Health Home Care Hospice dated 9/22/21, Green meadow hospice
On allegation Facility staff left resident unattended , the following are the findings.
Based on the interviews 6 staff, 4 out 6 staff reported that licensee was outside waiting for R 1’s daughter, standing by R 1’s wheelchair.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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
01/13/2022 and conducted by Evaluator Shobhana Frank
COMPLAINT CONTROL NUMBER: 22-AS-20220113165052

FACILITY NAME:COMFORT KEEPERS HOME CAREFACILITY NUMBER:
306005534
ADMINISTRATOR:MITRICA, CONSTANTIN EMILFACILITY TYPE:
740
ADDRESS:928 ORANGEWOOD DRTELEPHONE:
(714) 800-9249
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 6DATE:
09/16/2022
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Licensee Constantin MitricaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff placed resident in a wheelchair without doctor's order.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 contune -page -C

Facility staff placed resident in a wheelchair without doctor's order.
Based on reviewed of documents of Emanate Hospice care dated 9/22/21 patient information sheet indicates the order for wheelchair, and LIC 602 physician report dated 8/27/21 indicate that R 1 was using walker and wheelchair. Thus, the allegation is unfounded.
This agency has investigated the complaint alleging that Facility staff placed residnet in wheelchair without doctor's order, We have found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20220113165052
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: COMFORT KEEPERS HOME CARE
FACILITY NUMBER: 306005534
VISIT DATE: 09/16/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility staff left resident unattended is unsubstantiated. Based on the information gathered through interviews there was not a preponderance of evidence to prove or disprove that the Facility staff left resident unattended therefore, the allegation is UNSUBSTANTIATED.


On allegation that the resident is over medicated, the following are the findings. Per physician’s report dated 8/27/2021, Resident 1 has the primary diagnosis of age-related physical disability. Resident was admitted under Emanate Hospice care with terminal diagnosis of Alzheimer’s and dementia Resident was prescribed with Hydrocodone, Hyoscyamine pain medications as needed for pain. Based on medication record reviewed of, facility Medication Administration Medication chart (MAR), PRN Medication Log dated 11/1/21 to 11/9/21, on 11/2/21,11/3/21 and 11/4/21 R1 was in pain and PRN was given 4 times a day. Emanate Hospice medication log, Green Meadows Hospice Medication log, and interview of 6 staff- 6 of 4 staff reported PRN medications were given as needed (when R 1 in pain) ordered by the physician. the allegation that the Facility staff over medicated resident, Thus, the allegation is UNSUBSTANTIATED
Based on the information gathered through interviews there was not a preponderance of evidence to prove or disprove that the Facility staff left resident unattended therefore, the allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4