306005633-12-14-2023-22-AS-SSAS-CYXW4B-20231228155717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005633
Report Date: 12/14/2023
Date Signed: 12/14/2023 12:50:18 PM

Unfounded

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
12/11/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231211163815

FACILITY NAME:	MARYKNOLL SENIOR CARE		FACILITY NUMBER:	306005633
ADMINISTRATOR:	UMALI, FRANCES AMANDA		FACILITY TYPE:	740
ADDRESS:	531 WHITTEN WAY		TELEPHONE:	(805) 836-1556
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 4	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	08:34 AM
MET WITH:	Facility Administrator- Amanda Umali		TIME COMPLETED:	11:54 AM

ALLEGATION(S):

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Staff took photos of resident without consent.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility for the complaint received on 12/11/23 and to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by staff on duty (S1), and met with facility administrator (AD) Amanda Umali.

During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed.

It was alleged that staff took photos of resident without consent. Per record review, it was observed that all 4 residents (R1, R2, R3, R4) and/or their responsible party signed a "Permission to Photograph" form upon admission. The document stated that R1, R2, R3, and R4, may be photographed for the following reasons: resident file, activities/parties, accidents/injuries.

Unfounded

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: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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-20231211163815

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: MARYKNOLL SENIOR CARE	FACILITY NUMBER: 306005633
	VISIT DATE: 12/14/2023

NARRATIVE

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LPA conducted 4 resident interviews, of which all resident interviews did not corroborate with the allegation by stating that they are aware of the consent for photo taking, and expressed no concerns. LPA conducted a total of 3 staff interviews, of which all 3 interviews did not corroborate with the allegation by stating that photos of the resident would not be taken, unless specified and given consent via signed Permission to Photograph form.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, this allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with AD Umali.

A copy of this report was explained and provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

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