306005585-12-26-2023-22-AS-SSAS-CZ7Q37-20240105104814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005585
Report Date: 12/26/2023
Date Signed: 12/26/2023 03:53:07 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
09/20/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230920142902

FACILITY NAME:	VIVIDUS SENIOR LIVING		FACILITY NUMBER:	306005585
ADMINISTRATOR:	SHARIFAN, BAABAK		FACILITY TYPE:	740
ADDRESS:	25131 VIA PORTOLA		TELEPHONE:	(949) 584-0920
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	6	CENSUS: 5	DATE:	12/26/2023
		UNANNOUNCED	TIME BEGAN:	02:34 PM
MET WITH:	Staff on Duty - Edgardo Sevilla		TIME COMPLETED:	04:19 PM

ALLEGATION(S):

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Licensee did not abide by the terms of the admission agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by staff on duty (S1) Edgardo Sevilla, who notified facility administrator about the visit.

It was alleged that licensee did not abide by the terms of the admission agreement.

LPA De Perio conducted a total of 7 interviews. 5 out of the 5 interviews with residents did not corroborate with the allegation due to being unable to provide information regarding the allegation. 2 out of the 2 staff interviews conducted also did not corroborate with the allegation by stating that the facility does abide by the terms of the admission agreement, and disclosed that prior to admission, the facility administrator will go over the agreement with the residents responsible party, and that the responsible party will review and sign it.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

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-20230920142902

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: VIVIDUS SENIOR LIVING	FACILITY NUMBER: 306005585
	VISIT DATE: 12/26/2023

NARRATIVE

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Per documentation review, when resident (R1) moved into the facility, R1 was under an insurance agency that required the facility to provide monthly invoices. On August 29, 2023, R1's responsible party stated that R1 would be moving out by September 5, 2023. Per review of communication between R1's responsible party and facility administrator, an agreement was made that if R1 moved out of the facility by August 31, 2023, there would be no financial charges due to another resident wanting to move in. On September 1, 2023, a move-out invoice was issued to R1 for the amount of $175.00, however, it was removed by the facility.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA 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 S1.

A copy of this report was provided and explained.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023

LIC9099 (FAS) - (06/04)

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