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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005729
Report Date: 05/23/2024
Date Signed: 05/23/2024 09:57:30 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/14/2024 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240514125043
FACILITY NAME:CARE AYESHAFACILITY NUMBER:
306005729
ADMINISTRATOR:DEL ROSARIO, LESTERFACILITY TYPE:
740
ADDRESS:452 S SWIDLER PLACETELEPHONE:
(657) 281-2103
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 5DATE:
05/23/2024
UNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Maynard Datinguinoo-Caregiver, Angie Hernandez-LicenseeTIME COMPLETED:
10:12 AM
ALLEGATION(S):
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Staff did not report incidents involving residents to their authorized representatives
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on May 14, 2024. LPA was greeted and granted entry into the facility and met with Licensee Angie Hernandez and explained the reason for the visit. Administrator (AD) Lester A. Del Rosario arrived shortly after.

This agency has investigated the complaint alleging that staff did not report incidents involving residents to their authorized representatives. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Five of seven individuals interview denied the allegation. During the investigation LPA reviewed the Unusual Indident/Injury Report (UIIR) dated March 25, 2024 for Resident 1 (R1), R2 and R3. Per UIIR on March 22, 2024 R1, R2 and R3 were involved in a car accident, were escorted by the paramedics out of the vehicle and checked for injuries. During the course of the interviews with residents, R1 reported that it was a minor accident and
CONTINUED ON LIC9099-C...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
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-20240514125043
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARE AYESHA
FACILITY NUMBER: 306005729
VISIT DATE: 05/23/2024
NARRATIVE
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stated that staff notified his Power of Attorney. Per R2 the accident was not the staff's fault and stated that he is self responsible. During the course of the interviews with the authorized representatives for R1 and R3, the authorized representatives reported that they were notified right away and/or shortly after the accident.

Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations.
LPA Ramirez conducted an exit interview with AD Del Rosario, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC9099 (FAS) - (06/04)
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