306005566-3-19-2024-22-AS-AJLO-D4FPJ7-20240418112104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005566
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:31:18 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
09/14/2022 and conducted by Evaluator Claudia Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220914140712

FACILITY NAME:	A1 RCFE @ DELPHINE		FACILITY NUMBER:	306005566
ADMINISTRATOR:	VILLARMINO, SHIRLEY		FACILITY TYPE:	740
ADDRESS:	923 HUGGINS AVE		TELEPHONE:	(714) 399-5040
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 5	DATE:	03/19/2024
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Maryann Ednlig		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident was found wandering around in the community by law enforcement without any care and supervision.

INVESTIGATION FINDINGS:

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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above for the purpose of delivering findings. LPA met with Staff Maryann Ednlig. Administrator (AD) Shirley Villarmino arrived at 3:25 p.m.

During the initial investigation inspection conducted on 9/22/22, LPA interviewed AD who confirmed that on 9/13/22 at 11:30 a.m. during lunch time, she and another staff were looking for R1. Per AD, at 11:53 a.m., the police called and informed her R1 was found on the next street. Per AD, when she arrived R1 was sitting on the side of a planter, and he was with a medic. R1 declined medical assistance and a ride back to the facility from police. Facility ring camera time stamped at 12:05 p.m. shows R1 returned with AD to the facility in a wheelchair. Per AD, the neighbor called 911 because they saw R1 walking alone. Per AD, it was 35 minutes from the time R1 eloped to the time R1 returned to the facility with AD.
(Cont. LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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-20220914140712

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: A1 RCFE @ DELPHINE	FACILITY NUMBER: 306005566
	VISIT DATE: 03/19/2024

NARRATIVE

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Per Physician Reported dated 9/25/2018, R1 is diagnosed with dementia and has wandering behavior.

Based on AD admission, LPA determined that Resident was found wandering around in the community by law enforcement without any care and supervision. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated and a Deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. (See LIC9099-D).

An exit interview was conducted. A copy of this report, and appeal rights was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220914140712

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: A1 RCFE @ DELPHINE	FACILITY NUMBER: 306005566
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/20/2024 Section Cited HSC 1569.2(c)	1 2 3 4 5 6 7	“Care and supervision” means the facility assumes responsibility for, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidence by:	1 2 3 4 5 6 7	AD will conduct staff training regarding resident elopement, wandering behavior, and providing care and supervision and provide LPA with proof via email by POC date.
	8 9 10 11 12 13 14	Based on AD admission, they did not assume responsibility for resident's care and supervision, resulting in resident being found wandering around in the community by law enforcement, which posed an immediate health and safety risk to person in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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