306005743-5-29-2024-22-AS-AORZ-D5SNQS-20240531104025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005743
Report Date: 05/29/2024
Date Signed: 05/29/2024 10:57:21 AM

Unfounded

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
05/21/2024 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20240521145649

FACILITY NAME:	ASSURED CARE VILLA		FACILITY NUMBER:	306005743
ADMINISTRATOR:	DOMPREH-MENSAH, THERESA		FACILITY TYPE:	740
ADDRESS:	561 EAST SECOND AVE		TELEPHONE:	(310) 650-4190
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	6	CENSUS: 5	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Theresa Dompreh-Mensah		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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8
9

Staff are not adequately trained.
Facility is unsanitary

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator/ Licensee Theresa Dompreh-Mensah arrived during the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as training records.
Regarding the allegations that staff are not adequately trained and facility is unsanitary, the investigation revealed the following: LPA toured the facility during the visit and observed the facility is clean, safe and sanitary. No hazards were observed during the visit. LPA reviewed training records and four out of four staff have required annual training as well as medication training. Based on observations and record review, the allegations are deemed UNFOUNDED, meaning the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to Administrator.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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 4

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
05/21/2024 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20240521145649

FACILITY NAME:	ASSURED CARE VILLA		FACILITY NUMBER:	306005743
ADMINISTRATOR:	DOMPREH-MENSAH, THERESA		FACILITY TYPE:	740
ADDRESS:	561 EAST SECOND AVE		TELEPHONE:	(310) 650-4190
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	6	CENSUS: 5	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Theresa Dompreh-Mensah		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff verbally abuse residents
Staff do not ensure that resident is provided food in compliance with their special diet.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator/ Licensee Theresa Dompreh-Mensah arrived during the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and residents. Regarding the allegations that staff verbally abuse residents and staff do not ensure that resident is provided food in compliance with their special diet, the investigation revealed the following: Four out of four residents interviewed and three out of three staff interviewed deny staff verbally abuse residents. Four out of four residents state satisfaction with facility and indicate feeling safe. Per facility records and interview, Resident 1 (R1) has an allergy to corn. Staff as well as resident indicate resident does not receive corn in meals provided. Due to conflicting information, LPA is unable to corroborate the allegation. Therefore, the allegations are deemed 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 facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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

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
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
05/21/2024 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20240521145649

FACILITY NAME:	ASSURED CARE VILLA		FACILITY NUMBER:	306005743
ADMINISTRATOR:	DOMPREH-MENSAH, THERESA		FACILITY TYPE:	740
ADDRESS:	561 EAST SECOND AVE		TELEPHONE:	(310) 650-4190
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	6	CENSUS: 5	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Theresa Dompreh-Mensah		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not ensure that resident's are administered their medication(s) according to physician's instructions.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator/ Licensee Theresa Dompreh-Mensah arrived during the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as medication records. Regarding the allegation that staff do not ensure that resident's are administered their medication(s) according to physician's instructions, the investigation revealed the following: Two out of five resident medications are not being administered per physician order. Resident 1 did not receive morning administration of Mupirocin Ointment 2% on 05/27-05/29, 2024 and Resident 2 did not receive Diclofrnac Gel administered 05/27-05/29, 2024. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

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-20240521145649

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: ASSURED CARE VILLA	FACILITY NUMBER: 306005743
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/30/2024 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	Basic services shall at a minimum include: Personal assistance and care as needed by the resident... with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications.. This req is not being met as evidenced by:	1 2 3 4 5 6 7	Licensee to get discontinue orders for medications and forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record review, Licensee failed to ensure resident were assisted with administration of prescribed medications. R1 and R2 missed medication administration for 3 days. This poses an immediate health, safety 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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4