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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005766
Report Date: 03/07/2024
Date Signed: 03/07/2024 01:08:46 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
02/29/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240229132238
FACILITY NAME:NORA'S PLACE 2FACILITY NUMBER:
306005766
ADMINISTRATOR:AVENDANO, REINERFACILITY TYPE:
740
ADDRESS:25451 ADRIANA STREETTELEPHONE:
(949) 273-9951
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Mark Cruz, AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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9
Staff is failing to prevent an insect infestation.

Staff does not maintain the facility in a clean condition.
INVESTIGATION FINDINGS:
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5
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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 conducting the initial investigation into the four allegations listed above. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrators Mark Cruz and Eleonor Avendano were notified of the visit by telephone and arrived later to assist. Administrators were provided with the allegations upon their arrival.

LPA requested, obtained and reviewed resident records for the six individuals currently in care at the facility. LPA accompanied by administrators then conducted a tour of the physical plant and inspected two bathrooms used to provide toileting care to residents in addition to an additional bathroom in use by staff. LPA also toured the outside perimeter of the facility and verified the operation of multiple appliances throughout the facility.

CONTINUED ON FORM LIC9099
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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 7
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
02/29/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240229132238

FACILITY NAME:NORA'S PLACE 2FACILITY NUMBER:
306005766
ADMINISTRATOR:AVENDANO, REINERFACILITY TYPE:
740
ADDRESS:25451 ADRIANA STREETTELEPHONE:
(949) 273-9951
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Mark Cruz, Administrator
Eleonor Avendano, Administrator		TIME COMPLETED:
01:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are recording the residents and visitors without adequate authorization.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the four allegations listed above. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrators Mark Cruz and Eleonor Avendano were notified of the visit by telephone and arrived later to assist. Administrators were provided with the allegations upon their arrival.

LPA requested, obtained and reviewed resident records for the six individuals currently in care at the facility. LPA accompanied by administrators then conducted a tour of the physical plant and inspected two bathrooms used to provide toileting care to residents in addition to an additional bathroom in use by staff. LPA also toured the outside perimeter of the facility and verified the operation of multiple appliances throughout the facility.

CONTINUED ON FORM LIC9099
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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 7
Control Number 22-AS-20240229132238
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: NORA'S PLACE 2
FACILITY NUMBER: 306005766
VISIT DATE: 03/07/2024
NARRATIVE
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Regarding the allegation that Facility staff are recording the residents and visitors without adequate authorization, the following has been concluded: There are three video cameras observed in the facility's living room during the tour of the physical plant. Two of these are demonstrated to be a built-in system put in place by the facility's landlord, routed to a central console in a cupboard, and not currently in operation. A third camera is a remotely operated camera connected to the Internet. Footage received by the camera is accessible through an application on the licensee's phone.

A review of the resident's admission agreements found the presence of a signed Permission to Photograph issued to every resident and/or their authorized representative upon admission. The consent form however only states that "The facility will be photographing residents for the following reasons:
- New Resident File Photo
- Parties and Holidays Events
- Accident or injury to resident.
These photos will be considered confidential and will not be used for public use". Consent obtained to photograph residents does not extend to video footage obtained by the camera placed in the living room of the facility.

As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A corresponding Type B citation was issued on the attached form LIC9099-D.

An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 22-AS-20240229132238
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: NORA'S PLACE 2
FACILITY NUMBER: 306005766
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2024
Section Cited
CCR
87468.2(a)(1)
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7
Per CCR Section 87468.2(a)(1) "residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To have a reasonable level of personal privacy in accommodations(...)". This requirement is not met as evidenced by:
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Licensee removed the camera from the premises during the visit. Additionally, a consultation was provided to the licensee that operating the system can be permitted once adequate consent has been obtained from all the residents and/or their respective authorized representatives.
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Based on observation, one videosurveillance system was found to be in use in the facility's common area. Consent was not found to have been documented for the use of the camera. This constitutes a potential risk to the health, safety or personal rights of individuals in care.
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Deficiency cleared during the initial visit.
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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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 22-AS-20240229132238
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: NORA'S PLACE 2
FACILITY NUMBER: 306005766
VISIT DATE: 03/07/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099
Regarding the allegation that Staff is failing to prevent an insect infestation, the following has been concluded: Based on observation of the facility's physical plant conducted during today's visit, no evidence of an excessive accumulation of moisture was found in spite of the occurrence of a rain event less than 24 hours prior to the visit. Additionally, no evidence of an infestation of any kind was found during the visit. Facility staff was able to provide evidence of a pest control intervention occurring on February 27, 2024 at the facility's address.

Regarding the allegation that Staff does not maintain the facility in a clean condition, the following has been concluded: Based on observation of the facility's physical plant conducted during today's visit, all five bedrooms is use by current residents along with three bathrooms and common areas reviewed were all found to be clean and free of obstructions. No evidence of a failure to maintain adequate cleanliness was found around the physical plant.

The two allegations are therefore found to be Unfounded, meaning that the allegations are false, could not have happened and/or are without a reasonable basis.

An exit interview was conducted and a copy of the report was provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7
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
02/29/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240229132238

FACILITY NAME:NORA'S PLACE 2FACILITY NUMBER:
306005766
ADMINISTRATOR:AVENDANO, REINERFACILITY TYPE:
740
ADDRESS:25451 ADRIANA STREETTELEPHONE:
(949) 273-9951
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Mark Cruz, AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility bathrooms have rust.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the four allegations listed above. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrators Mark Cruz and Eleonor Avendano were notified of the visit by telephone and arrived later to assist. Administrators were provided with the allegations upon their arrival.

LPA requested, obtained and reviewed resident records for the six individuals currently in care at the facility. LPA accompanied by administrators then conducted a tour of the physical plant and inspected two bathrooms used to provide toileting care to residents in addition to an additional bathroom in use by staff. LPA also toured the outside perimeter of the facility and verified the operation of multiple appliances throughout the facility.

CONTINUED ON FORM LIC9099
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20240229132238
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: NORA'S PLACE 2
FACILITY NUMBER: 306005766
VISIT DATE: 03/07/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099
Regarding the allegation that Facility bathrooms have rust, the following has been concluded: Based on observation of the facility's physical plant conducted during today's visit, the two bathrooms in use to provide toileting care to residents in care are found to be equipped with all necessary items and are observed to be clean and in good repair. There is presence of rust near the shower head of a third bathroom, however that shower is not in use for the benefits of the residents due to the presence of an excessive threshold barring mobility-impaired residents from accessing the shower. Per interviews conducted, the bathroom is only in use for the current live-in caregivers.

As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no 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 a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7