306005810-8-26-2022-22-AS-LADS-CHZUNY-20220906154444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005810
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:41:21 PM

Unsubstantiated

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
12/30/2021 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20211230093410

FACILITY NAME:	DEVOTED FAMILY CARE HOME		FACILITY NUMBER:	306005810
ADMINISTRATOR:	PICENO, CASSANDRA		FACILITY TYPE:	740
ADDRESS:	12041 GILBERT ST		TELEPHONE:	(714) 949-1351
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	6	CENSUS: 4	DATE:	08/26/2022
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Jonathan Tolentino		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff are not meeting resident's care needs
Staff provoke resident
Resident is over medicated

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to this facility to deliver findings on the complaint 22-AS-20211230093410. LPA Haley was granted entry, and stated the reason for the visit. Facility staff called Administrator (AD) Claudia Olteanu via telephone and LPA Haley explained th reason for the visit to AD Olteanu.

Please see findings below:

Regarding the allegation: Staff are not meeting resident’s care needs.
During the initial 10 day visit on 1/10/22, and a unannounced visit made on 1/12/22, LPA’s Jerome Haley and Joseph Alejandre interviewed staff members who confirmed that R1 is provided with meals, snacks, provided the opportunity to shower every morning, and encouraged to go outside to get fresh air. R1 speaks with his brother regularly, and arrangements have been made for R1 to visit and spend time with his brother. During subsequent visits during the investigation LPA Haley observed other residents in the home enjoying television and music during the day.
Continued on LIC 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20211230093410

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: DEVOTED FAMILY CARE HOME	FACILITY NUMBER: 306005810
	VISIT DATE: 08/26/2022

NARRATIVE

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Based on the information gathered during the investigation, review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

Regarding the allegation: Staff provoke resident.

During the investigation, all staff members interviewed denied the allegation that staff provoke the resident. None of the staff members admitted to provoking R1 or witnessing any staff member provoke R1 at any time. During the investigation, it was revealed through multiple interviews that R1 can be difficult, agitated, aggressive, and will act out. Based on the information gathered this allegation is deemed Unsubstantiated.

Regarding the allegation: Resident is over medicated.

During the initial visit on 1/10/22, AD Oleantu provided copies of the Centrally Stored Medication and Destruction Record, and Medication Administration Record. Through record review all medication for R1 was administered as prescribed. R1 is prescribed the anti-psychotic medication Rexulti and a couple side effects are behavioral changes such as anger or aggression. R1 is also prescribed a mood stabilizer medication Divalproex ER and some of the side effects are dizziness, drowsiness, and weakness. Further, R1 stated during our interview, that he takes a lot of medication. Based on the information gathered this allegation is deemed Unsubstantiated.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC9099 (FAS) - (06/04)

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