306005733-8-3-2023-22-AS-SSAS-CUKQFV-20230810120833

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005733
Report Date: 08/03/2023
Date Signed: 08/03/2023 03:19:19 PM

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
07/06/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230706114911

FACILITY NAME:	AVALON GUEST MANOR I		FACILITY NUMBER:	306005733
ADMINISTRATOR:	SHARIFI, MARYAM FARINAZ		FACILITY TYPE:	740
ADDRESS:	1857 SHEDDON ST		TELEPHONE:	(714) 869-3532
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	6	CENSUS: 4	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Sina Sharifi, house manager		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Licensee does not ensure admission agreement discloses fees charged to residents.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the complaint investigation and deliver findings to the licensee. LPA was greeted and granted entry by facility staff after explaining the purpose of the visit. Allegations were listed again to facility staff.

On July 10, 2023, LPA conducted an initial complaint investigation visit. LPA requested, obtained and reviewed employee records as well as resident records for all four residents currently admitted to the facility and one recently discharged resident, including physician records, individual needs assessements and admission agreements for each of those. Facility staff additionally demonstrated that resident R1's belongings have been packed up and are ready to be collected by the resident's relatives but are still at the facility along with medical equipment provided by Home Health services.

CONTINUED ON FORM LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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 4

Control Number 22-AS-20230706114911

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: AVALON GUEST MANOR I	FACILITY NUMBER: 306005733
	VISIT DATE: 08/03/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099

Administrator Faye Sharifi submitted additional documentation of payments made to the facility along with an amended admission agreement for resident R1 on July 14, 2023.

Regarding the allegation that Licensee does not ensure admission agreement discloses fees charged to residents, the following has been concluded: Admission agreements for the three residents living at the facility at the time of the initial visit were reviewed along with the initialed and signed copy of the admission agreement for resident R1. All residence fees and additional fees applicable such as incontinence supplies are confirmed to be present on the documents. Additional interview with witness W1 confirmed that no additional deposits or facility fees were charged and/or paid to the licensee after resident R1 was admitted and resided at the facility. No refunds to the responsible party of resident R1 were offered as the facility was not given as 30-day notice as stated in the admission agreement. Therefore the allegation is deemed to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided to facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
07/06/2023 and conducted by Evaluator Kevin Saborit-Guasch

COMPLAINT CONTROL NUMBER: 22-AS-20230706114911

FACILITY NAME:	AVALON GUEST MANOR I		FACILITY NUMBER:	306005733
ADMINISTRATOR:	SHARIFI, MARYAM FARINAZ		FACILITY TYPE:	740
ADDRESS:	1857 SHEDDON ST		TELEPHONE:	(714) 869-3532
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	6	CENSUS: 4	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Sina Sharifi, house manager		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff are withholding resident’s personal belongings.

INVESTIGATION FINDINGS:

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13

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the complaint investigation and deliver findings to the licensee. LPA was greeted and granted entry by facility staff after explaining the purpose of the visit. Allegations were listed again to facility staff. Facility administrator was notified of the visit via telephone and arrived later to assist.

On July 10, 2023, LPA conducted an initial complaint investigation visit. LPA requested, obtained and reviewed employee records as well as resident records for all four residents currently admitted to the facility and one recently discharged resident, including physician records, individual needs assessements and admission agreements for each of those. Facility staff additionally demonstrated that resident R1's belongings have been packed up and are ready to be collected by the resident's relatives but are still at the facility along with medical equipment provided by Home Health services.

CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20230706114911

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: AVALON GUEST MANOR I	FACILITY NUMBER: 306005733
	VISIT DATE: 08/03/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099-A

Regarding the allegation that: Staff are withholding resident’s personal belongings, the following has been concluded: At the time of resident R1's discharge from the facility following an hospitalization, there is a disagreement between facility staff and the resident's responsible party/conservator on the amount that remained due as part of the resident's facility fees. One witness interviewed stated that the resident's relatives had not been permitted to retrieve the personal items.

Multiple staff interviews however indicated that arrangements had been made for a pick-up on July 8 or July 9, 2023, which they corroborated with screen captures of text messages. At the time of the present visit, the resident's belongings are still at the facility after the responsible party made no further attempt to contact the facility. The threats involving the resident's belongings in response to a billing dispute cannot be fully corroborated, nor can it be fully excluded that they were initially made. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was provided to facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

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