306005773-7-26-2023-22-AS-AORZ-CU9P56-20230731110014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005773
Report Date: 07/26/2023
Date Signed: 07/26/2023 03:00:46 PM

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
04/11/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220411101642

FACILITY NAME:	FAMILY CHOICE SENIOR LIVING		FACILITY NUMBER:	306005773
ADMINISTRATOR:	HUNDLEY, SHANNON		FACILITY TYPE:	740
ADDRESS:	3105 W. ORANGE STREET		TELEPHONE:	(714) 229-0069
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	30	CENSUS: 13	DATE:	07/26/2023
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Pamela Junge		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to ensure resident receive social security checks
Facility refuses to refund admission fees.

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 deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as facility correspondence. Regarding the allegations that facility refuses to refund admission fees and facility failed to ensure resident receive social security checks, the investigation revealed the following: Resident 1 (R1) admitted into the facility on 03/02/2022 and discharged the next day. R1's responsible party did not provide a thirty day notice. However, facility processed a refund for family in the amount of $1277.33 on 03/22/2022. Administrator indicated the payment came directly from the family and social security payments had not been set up as resident was only at
the facility for a day. Administrator denied receiving any social security checks and provided email correspondence indicating a willingness to assist family with any issues they were having with social security post discharge. CONTINUED ON LIC 9099C DATED 07/26/2023

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: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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 3

Control Number 22-AS-20220411101642

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: FAMILY CHOICE SENIOR LIVING	FACILITY NUMBER: 306005773
	VISIT DATE: 07/26/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on observations and interviews, 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 facility representative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
04/11/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20220411101642

FACILITY NAME:	FAMILY CHOICE SENIOR LIVING		FACILITY NUMBER:	306005773
ADMINISTRATOR:	HUNDLEY, SHANNON		FACILITY TYPE:	740
ADDRESS:	3105 W. ORANGE STREET		TELEPHONE:	(714) 229-0069
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	30	CENSUS: 13	DATE:	07/26/2023
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Pamela Junge		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident hit on the face by staff.

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 deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as facility correspondence. Regarding the allegation that resident hit on the face by staff, the investigation revealed the following: R1 admitted into the facility on 03/02/2022 after residing at home. Resident was only at the facility for one day. R1 was exhibiting aggressive behaviors toward staff. Facility was preparing to call 911 when family arrived and took the resident home. Four out of four staff deny any knowledge or observation of any staff hitting the resident. Resident is diagnosed with Dementia and LPA was not provided the opportunity to interview R1. Due to conflicting information, LPA is unable to corroborate allegations. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided.

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: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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 3