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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005773
Report Date: 08/08/2023
Date Signed: 08/08/2023 10:14:37 AM

Substantiated


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
06/23/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20210623102145
FACILITY NAME:FAMILY CHOICE SENIOR LIVINGFACILITY NUMBER:
306005773
ADMINISTRATOR:REHBEIN, ERINFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 15DATE:
08/08/2023
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Pamela JungeTIME COMPLETED:
10:35 AM
ALLEGATION(S):
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Staff are not following a resident's needs while in care
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to deliver findings on the above allegation. LPA was granted entry by Administrator Pamela Junge 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 Physician Report and Appraisal Needs and Services plan. Regarding the allegation that staff are not following a resident's needs while in care, the investigation revealed the following: Per Appraisal Needs and Services dated 01/05/2020 and 05/28/2021, Resident 1 (R1) is a two person assist. Administrator indicated staffing shortages and staff schedule during complaint time frame showed three caregivers on the schedule besides Administrator. Facility staff indicated working alone on many occasions and having difficulty with assisting R1 due to R1's status of two person assist. Physician report dated 05/28/2021 indicated the resident was unable to perform activities of daily living. The preponderance of evidence standard has been met, therefore the above allegation is CONTINUED ON LIC 9099C DATED 08/08/2023.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
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 5
Control Number 22-AS-20210623102145
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: 08/08/2023
NARRATIVE
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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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/23/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20210623102145

FACILITY NAME:FAMILY CHOICE SENIOR LIVINGFACILITY NUMBER:
306005773
ADMINISTRATOR:REHBEIN, ERINFACILITY TYPE:
740
ADDRESS:3105 W. ORANGE STREETTELEPHONE:
(714) 229-0069
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:30CENSUS: 15DATE:
08/08/2023
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Pamela JungeTIME COMPLETED:
10:35 AM
ALLEGATION(S):
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Staff threatened a resident with eviction
Staff are not following the admission agreement
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to dekiver findings on the above allegation. LPA was granted entry by Administrator Pamela Junge 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 documention such as eviction notice and admission agreement. Regarding the allegations that staff threatened a resident with eviction and staff are not following the admission agreement, the investigation revealed the following: Resident 1 (R1) was reassessed 05/28/2021 and determined to be bedridden per physician report. Facility does not have bedridden fire clearance and R1 was provided an eviction notice on 08/24/2021. Witness indicates being verbally told prior that the resident will be evicted. Admission agreement dated 07/28/2019 indicates a basic fee of $5000 per month without any indications of additional pricing. Facility is unable to provide any additonal price updates or amendements to the admission agreement. Administrator denies requiring R1 to change insurance during tenure at the facility.
CONTINUED ON LIC 9099C DATED 08/08/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
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 5
Control Number 22-AS-20210623102145
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: 08/08/2023
NARRATIVE
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Due to conflicting information, LPA is unable to corroborate the allegations. 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 violation occurred.

An exit interview was conducted with Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20210623102145
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2023
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Licensee to forward a statement of understanding regarding the regulation to LPA by POC due date.
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Based on interviews conducted and record review, Licensee failed to ensure care and supervision was being provided to R1. Facility was not following care plan due to staffing issues. This poses an immediate health and safety risk to residents in care.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5