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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005829
Report Date: 12/08/2023
Date Signed: 12/08/2023 04:22:34 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
07/23/2021 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210723122920
FACILITY NAME:MT. SHERROD HOME, LLC.FACILITY NUMBER:
306005829
ADMINISTRATOR:LASALA-DOAN, GERALDINEFACILITY TYPE:
740
ADDRESS:16550 MT. SHERROD CIRCLETELEPHONE:
(714) 839-4417
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
12/08/2023
UNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Geraldine Lasala-Doan, AdministratorTIME COMPLETED:
03:43 PM
ALLEGATION(S):
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-Staff will not provide resident's doctor with history of care.
INVESTIGATION FINDINGS:
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose to conduct additional interviews, review documentation and deliver findings for complaint allegation listed above. LPA Quiroz was greeted and granted entry by Caregiver Jovita Manaloto and called and spoke to Administrator (AD) Geraldine Lasala-Doan via telephone and discussed purpose of today's visit. (AD) Geraldine Lasala-Doan arrived during today's visit. The 10 day visit was conducted on 8/02/2021 by LPA Joseph Alejandre.
During the course of the investigation, LPA Quiroz and LPA Alejandre conducted interviews with interviewees consisting of staff and witness. LPA Quiroz also conducted documentation review but not limited to resident roster, staff roster, physician report, identification form, needs and services plan and Admission Agreement for Resident 1 (R1) and Resident 2 (R2).
Regarding the allegation, "Staff will not provide resident's doctor with history of care" the investigation revealed the following: Interviewee interviewed indicated that requested information was received as requested from the Hospice company and that information was forwarded it to the new doctor. CONT...
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
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 2
Control Number 22-AS-20210723122920
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: MT. SHERROD HOME, LLC.
FACILITY NUMBER: 306005829
VISIT DATE: 12/08/2023
NARRATIVE
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CONTINUED... Witness indicated that the facility was not involved in the information exchange and that the facility has never withheld anything requested from (R1), (R2) and Responsible Party. In addition, the investigation revealed that the responsible party for (R1) and (R2) is the only person who is allowed to make decisions for (R1) and (R2) and the only person allowed to release or have access to their information other than the facility and the doctors.

Therefore based on the preponderance of evidence gathered through interviews and documentation review, the allegations that the "Staff will not provide resident's doctor with history of care" is deemed UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint.

No deficiencies cited during today's visit.
An exit interview was conducted with (AD) Geraldine Lasala-Doan and a copy of this report and LIC 811- Confidential Names were provided at exit.









SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2