306005785-9-4-2024-22-AS-AORZ-D943WY-20240913183732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005785
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:33:10 PM

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
08/26/2024 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20240826114350

FACILITY NAME:	B & C ELDERLY CARE		FACILITY NUMBER:	306005785
ADMINISTRATOR:	ESTORBA, BRIAN A.		FACILITY TYPE:	740
ADDRESS:	9342 LIME CIRCLE		TELEPHONE:	(714) 488-8413
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90630
CAPACITY:	6	CENSUS: 5	DATE:	09/04/2024
		UNANNOUNCED	TIME BEGAN:	02:01 PM
MET WITH:	John Eugenio		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff does not assist resident with care needs in a timely manner

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 allegation. 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 and interviewed resident and staff. Regarding the allegation that staff does not assist resident with care needs in a timely manner, the investigation revealed the following: Resident 1 (R1) indicated needing incontinence care and requesting from Staff 1. Incontinence care was not provided resulting in resident remaining soiled through the night. Interview with staff indicated an awareness of the situation occurring. R1 indicated requesting a facial wipe from S1 for cleansing and not receiving the wipe for 3 days. Staff confirm the incident. Assistant Administrator as well as staff state S1 was released from duty on 08/30/2024 and is no longer employed at the facility. Based on interviews conducted, 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: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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 3

Control Number 22-AS-20240826114350

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: B & C ELDERLY CARE	FACILITY NUMBER: 306005785
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/18/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This req is not being met as evidenced by:	1 2 3 4 5 6 7	Licensee to provide retraining on personal rights and forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted, Licensee failed to ensure residents are afforded dignity in the facility. R1 was left soiled and not provided requested supplies. This poses a potential health and safety 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: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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
08/26/2024 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20240826114350

FACILITY NAME:	B & C ELDERLY CARE		FACILITY NUMBER:	306005785
ADMINISTRATOR:	ESTORBA, BRIAN A.		FACILITY TYPE:	740
ADDRESS:	9342 LIME CIRCLE		TELEPHONE:	(714) 488-8413
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90630
CAPACITY:	6	CENSUS: 5	DATE:	09/04/2024
		UNANNOUNCED	TIME BEGAN:	02:01 PM
MET WITH:	John Eugenio		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff does not provide residents with adequate food service

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 allegation. 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 and interviewed resident and staff. Regarding the allegation that staff does not provide residents with adequate food service, the investigation revealed the following: LPA observed food supply during the visit. Facility has ample fresh and varied foods for residents. LPA observed pictures of plated foods provided to the residents and the selections were varied. Two out of three residents interviewed confirm food is provided warm and of good quality. Two out of three residents indicated S1 was not an adequate cook but the food was still acceptable. LPA was provided the grocery shopping list and the items requested were appropriate and healthful. Due to conflicting information, LPA is unable to corroborate the allegation. 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 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: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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 3