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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005705
Report Date: 06/17/2022
Date Signed: 06/17/2022 10:33:21 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
05/18/2022 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220518131217
FACILITY NAME:EDWARD BOARD AND CARE HOMEFACILITY NUMBER:
306005705
ADMINISTRATOR:HERNANDEZ, MARISAFACILITY TYPE:
735
ADDRESS:117 EDWARD AVE.TELEPHONE:
(714) 290-3809
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:4CENSUS: 3DATE:
06/17/2022
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Justin Rodriguez - Caregiver TIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility did not have food in the refrigerator, and no dinner available for clients.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to investigate the above allegation and to deliver the findings of the investigation. LPA Velazquez was allowed entry into the facility and met with Caregiver Justin Rodriguez.

On today's visit LPA Velazquez conducted interviews with staff and the client present. LPA also conducted a brief tour of the physical plant focusing on the kitchen. LPA and Caregiver observed fresh fruit on the dining table which included a pineapple, nectarines, apples, and bananas. There was an adequate supply of perishable and non-perishable food present in the facility observed during today's visit. LPA Kathrina Chin conducted a Case Management visit to the facility on 06/16/2022 where LPA Chin noted an insufficient supply of food.

During the course of the investigation LPA reviewed facility, staff, and client records. Records reviewed
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
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 2
Control Number 22-AS-20220518131217
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: EDWARD BOARD AND CARE HOME
FACILITY NUMBER: 306005705
VISIT DATE: 06/17/2022
NARRATIVE
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included Client and Staff Rosters, Staff Schedules, Consumer Face Sheet, Identification and Emergency Information, Preplacement Appraisal Information, Appraisal Needs and Service Plans, Physician's Reports, and Individual Program Plans (IPPs). LPA Velazquez was also provided with pictures of the refrigerator and freezer as well as grocery receipts for the facility's food supply. LPA Velazquez also conducted interviews with staff and a client who were not able to corroborate the above allegation. LPA Velazquez spoke with Administrator Marisa Hernandez on the phone during today's visit. Administrator Hernandez agreed to provide pictures of the refrigerator and freezer along with copies of grocery receipts for the next six weeks and submit them to LPA Velazquez.



Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the following allegation: Facility did not have food in the refrigerator, and no dinner available for clients is deemed UNSUBSTANTIATED.


An exit interview was conducted with Caregiver Justin Rodriguez and a copy of this report along with the LIC 811s were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2