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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005729
Report Date: 12/23/2024
Date Signed: 12/23/2024 01:20:06 PM

Unsubstantiated


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
12/27/2021 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20211227160124
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: 4DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Staff #1 TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Covid-19 masking protocols are not being followed
Residents were left unsupervised while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced complaint visit to deliver findings from a complaint received in our office on December 27, 2021. LPA received permission from Licensees to leave report with Staff #1, since they were offsite for Bingo. LPA stated the purpose of the visit to Licensees, via phone, and with Staff #1.

LPA obtained and reviewed the following documents: Register of Facility Residents from January 5, 2022, LIC 500 Staff Roster, LIC 624 Unusual Incident Report, Resident LIC 601 Identification and Emergency Information, LIC 602A Physician’s Report for RCFE, LIC 603 Preplacement Appraisal Information, and LIC 603A Resident Appraisal. LPA also reviewed PIN 21-38-ASC-the Provider Information Notice on Updated Guidance for the Use of Face Masks, Surgical Masks, and Respirators Related to Coronavirus Disease 2019 (COVID-19) dated August 19, 2021 and PIN 21-21-CCLD COVID-19 Safety Recommendations for the Upcoming Holiday Season dated October 29, 2021.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
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-20211227160124
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: 12/23/2024
NARRATIVE
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(Continued from LIC 9099)
During the investigation LPA interviewed three of three staff members, three of three witnesses from the incident on December 27, 2021. Regarding the allegation that masking protocols were not followed, three of three staff members stated they wore masks during that time and that residents were not mandated to wear them since they lived at the residence. All of the residents from the incident date no longer reside at the facility and were not available for interview. One witness stated masks were not being worn by staff. Another witness could not recall if masks were worn. LPA Rosie Quiroz conducted the ten day visit on January 6, 2022 and observed staff were wearing masks. Based on LPA interviews and observations, the allegation that COVID-19 masking protocols were not being followed is Unsubstantiated.

LPA Ruppert conducted six of six interviews regarding residents being left unsupervised while in care. Three of three staff stated they were present at the facility. Two of the staff members reside at the facility and stated one was outside throwing away trash and the other staff member was transferring laundry. Two of two witnesses stated the staff members were not inside the facility and were in the backyard. Although staff members were not in close proximity to the residents, staff members remained on the facility property and were available to residents if needed.

Therefore, based on interviews conducted and documents reviewed, the allegations Covid-19 masking protocols are not being followed and Residents were left unsupervised while in care are deemed to be Unsubstantiated.

Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Staff #1 and a copy of this report and Technical Advisory LIC 9102-TA was provided to the facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
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