306005721-5-24-2022-22-AS-SSAS-CQ7VWE-20230323164747

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005721
Report Date: 05/24/2022
Date Signed: 05/24/2022 03:24:36 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
03/11/2022 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220311135355

FACILITY NAME:	CYECREST GUEST HOME		FACILITY NUMBER:	306005721
ADMINISTRATOR:	LUU, CHI V		FACILITY TYPE:	740
ADDRESS:	139 S LINCOLN STREET		TELEPHONE:	(714) 785-9555
CITY:	ORANGE	STATE: CA	ZIP CODE:	92866
CAPACITY:	6	CENSUS: 3	DATE:	05/24/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Mary Jean Alvarado		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident was illegally evicted

INVESTIGATION FINDINGS:

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Licensing Program Analyst Michelle Reed arrived at the facility to deliver findings of this complaint investigation. Upon arrival, LPA met with Staff Jason "J" Flake and Pouya "Paul" Ghorbanpour. Licensee Tin Le was contacted via telephone. He stated that he was at an appointment and Administrator Chi Luu was out of town. Mary Jean Alvarado was contacted by Mr. Le and he stated that she would sign the report upon his behalf. Ms. Alvarado arrived at approximately 1:45pm.
The investigation consisted of interviews with Administrator Chi Luu, staff and witnesses as well as documentation. The following was determined: R1 was evicted from the facility on 3/9/22 and moved to an RCFE in Garden Grove. The Licensee and Administrator did not give Resident #1 or her responsible party a 30 day written notice. According to Administrator Chi Luu a verbal notice was given to R1's responsible party. Based upon interviews, the preponderance of evidence standard has been met and the above allegation is substantiated. See attached LIC9099D for cited deficiencies per California Code of Regulations, (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report and appeal rights were provided to Mary Jean Alvarado. A copy of this report will be also be mailed to the Licensee.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

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-20220311135355

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: CYECREST GUEST HOME	FACILITY NUMBER: 306005721
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/25/2022 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	Eviction Procedures- The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty days written notice to the resident is required. In addition, the Licensee must notify or mail a copy of the notice to quit to the resident's responsible person. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to review 87224 Eviction Procedures and provide proof of understanding that a 30 day notice should be issued before a resident is evicted.
	8 9 10 11 12 13 14	Licensee failed to give Resident #1 and/or her responsible party a 30 day written notice of eviction This poses an immediate Health and Safety and/or Personal Rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

LIC9099 (FAS) - (06/04)

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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
03/11/2022 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220311135355

FACILITY NAME:	CYECREST GUEST HOME		FACILITY NUMBER:	306005721
ADMINISTRATOR:	LUU, CHI V		FACILITY TYPE:	740
ADDRESS:	139 S LINCOLN STREET		TELEPHONE:	(714) 785-9555
CITY:	ORANGE	STATE: CA	ZIP CODE:	92866
CAPACITY:	6	CENSUS: 3	DATE:	05/24/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Mary Jean Alvarado		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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5
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7
8
9

Facility staff had a physical altercation with resident
Facility staff made inappropriate comments to resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst Michelle Reed arrived at the facility to deliver findings of this complaint investigation. Upon arrival, LPA met with Staff Jason "J" Flake and Pouya "Paul" Ghorbanpour. Licensee Tin Le was contacted via telephone. He stated that he was at a meeting and Administrator Chi Luu was out of town. Mary Jean Alvarado was contacted by Mr. Le and he stated that she would sign the report upon his behalf. Ms. Alvarado arrived at approximately 1:45pm. The investigation consisted of interviews with Administrator Chi Luu, staff and witnesses as well as documentation. The following was determined:

R1 was admitted into the facility on 3/31/20. R1 had lived at the facility since 3/1/16 before a change of ownership. Records and interviews disclosed that R1 had a difficult time expressing her needs and would often become verbally and physically aggressive. R1 also needed assistance with all ADL's. Based upon interviews and records reviewed, the allegations are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to Mary Jean Alvarado and a copy will be mailed to the Licensee.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022

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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