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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005827
Report Date: 11/23/2022
Date Signed: 11/23/2022 11:22:50 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
11/18/2022 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221118171111
FACILITY NAME:COZY HOME SENIOR CAREFACILITY NUMBER:
306005827
ADMINISTRATOR:DUMALIANG, CZARINA SFACILITY TYPE:
740
ADDRESS:22272 TERNITELEPHONE:
(949) 583-9365
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 6DATE:
11/23/2022
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Czarina DumaliangTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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-Staff are not ensuring that smoke detectors are in working condition

-Staff are not ensuring that bathroom toilets are in working condtion
INVESTIGATION FINDINGS:
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This unannounced visit conducted by Licensing Program Analyst (LPA) Ruth Martinez is being conducted to initiate the 10 day visit to investigate the above mentioned complaint allegation. LPA arrived at facility was greeted at the door by caregiver and granted entry. LPA met with caregiver and explained the nature of today’s visit. Czarina Dumaliang, Administrator arrived shortly after and met with LPA and explained the nature of the visit and allegations were explained.

Findings are based upon this investigation which included interview conducted and tour of the physical plant of the facility.

It is alleged that staff are no ensuring that smoke detectors are in working condition and staff are not ensuring that bathroom toilets are in working condition. LPA toured the physical plant of the facility and tested smoke

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
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-20221118171111
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: COZY HOME SENIOR CARE
FACILITY NUMBER: 306005827
VISIT DATE: 11/23/2022
NARRATIVE
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detectors. LPA observed that upon testing smoke detector in room 4 no sound came from device. LPA asked S1 to remove smoke detector from ceiling, upon removal LPA observed smoke detector to not have any batteries and was not functioning. Upon further inspection of all smoke detectors LPA observed smoke detector in hallway to resident bedrooms to have no sound came from device. LPA had S1 remove smoke detector from ceiling, upon removal LPA observed smoke detector to have only 2 batteries out of 3 that are required in order to function. Interview with staff 1 of 2 revealed that S1 indicated he forgot to put batteries in smoke detectors. Upon inspections of facility bathrooms LPA observed bathroom in bedroom 4 to be properly functioning. However common bathroom of the facility was observed to have water tank lid open. LPA inspected toilet and flushed toilet; it was observed that the toilet flush valve was not working properly. Upon flushing of the toilet, it was observed that the flush valve has a vertical overflow tube that extends from the base of the flush valve up into the tank. The tube was observed to move upward upon flushing and does not move downwards without assistance which can causes the flow of water to not fill the water tank properly. Interview with S1 revealed that toilet for common bathroom has been this way for about a month.

During the course of the investigation, there was sufficient evidence to substantiate the allegation of that staff are no ensuring that smoke detectors are in working condition and staff are not ensuring that bathroom toilets are in working condition. The preponderance of evidence standard has been met; therefore, the above allegations are substantiated. See LIC9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator and a copy of this LIC9099 report was left at facility. Appeal rights reviewed, and a copy provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20221118171111
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: COZY HOME SENIOR CARE
FACILITY NUMBER: 306005827
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2022
Section Cited
CCR
87203
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FIRE SAFETY: All facilities smoke detectors shall be maintained in conformity with the regs adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not being as evidenced by: LPA observed bedroom 4 smoke detector to not have batteries and was inoperable, hallway smoke detector
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LPA at the time of visit observed S1 place batteries in smoke detectors. LPA tested smoke detectors an observed them to properly function at this time.

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was found inoperable with only obtained 2 batteries. Smoke detector requries 3 batteries to operate properly. This poses an immediate health and safety risk to residents in care.
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Licensee will review section cited and submit a written acknowledgment signed to CCL by POC date.
Type A
11/24/2022
Section Cited
CCR
87303(e)(6)
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Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the
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Licensee to ensure all toilet, handwashing and bathing facilities shall be maintained in operating condition at all times. Licensee to repair or replace the toilet located in common bathroom. Licensee to submit proof of all repairs to LPA by POC due date.
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residents' needs. This requirement is not met as evidenced by: based on observation and interview the the common bathroom toilet not properly functioning. This poses a potential risk to the health & safety of 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC9099 (FAS) - (06/04)
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