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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005644
Report Date: 04/15/2024
Date Signed: 04/15/2024 03:37:40 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
12/21/2023 and conducted by Evaluator Jerome Haley
COMPLAINT CONTROL NUMBER: 22-AS-20231221161333
FACILITY NAME:NOUMEA CARE HOME IIIFACILITY NUMBER:
306005644
ADMINISTRATOR:BURGOS, CONSOLACION SFACILITY TYPE:
735
ADDRESS:6356 SHERMAN WAYTELEPHONE:
(714) 788-9165
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:4CENSUS: 1DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Karen Saturno - AdministratorTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility staff failed to properly secure medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced follow up visit to the facility to close and deliver findings on the complaint allegation made December 21, 2023. LPA Haley was greeted by staff and explained the reason for the visit.
The complaint investigation consisted of interviews with facility staff, a facility client, and document review.

Regarding the complaint allegation: Facility staff failed to properly secure medications.
During interviews 3 of 3 individuals interviewed confirmed the complaint allegation above. Client 1 (C1) medications were observed unsecured on top of the client’s dresser during an unannounced visit from the Regional Center on December 15, 2023.
Based on the evidence gathered through interviews and observations, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6.
An exit interview was conducted, and a copy of this report, and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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 2
Control Number 22-AS-20231221161333
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: NOUMEA CARE HOME III
FACILITY NUMBER: 306005644
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
80075(k)(1)
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80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
The following requirement is not being met as evidenced by:
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During the visit, medications were immediately taken out of the clients room and secured with the rest of the medications and the discontinued medication was disposed of. An in-service training on client medications was held for all staff. Administrator Karen Saturn agrees to keep all client medications locked and secured at all times in accordance with regulations guidelines.
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During an unannounced visit by the regional center on December 15, 2023, unsecured medications were observed in the client's room on top of the dresser. This poses a health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
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