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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005866
Report Date: 03/16/2023
Date Signed: 03/16/2023 03:20:12 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
02/23/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230223080804
FACILITY NAME:ELEONOR'S PLACE 2FACILITY NUMBER:
306005866
ADMINISTRATOR:AVENDANO, DARYLLFACILITY TYPE:
740
ADDRESS:24772 ARGUS DRIVETELEPHONE:
(949) 547-5377
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
03/16/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Vangie Pablo- CaregiverTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff are prohibiting resident from having visitors.
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Vangie Pablo, caregiver and explained the reason for the visit. Administrator Mark Cruz arrived shortly after.

The department received a complaint on 02/23/2023 and the initial visit was conducted on 03/02/2023 by LPA Kimberly Lyman. LPA Lyman interviewed Administrators Mark Cruz and Eleanor Avenado and obtained copies of physician's report, emergency contact information and medication administration records for Resident 1 (R1). Regarding the allegation staff are prohibiting resident from having visitors, the investigation revealed the following:

It was reported by witnesses that R1 was not allowed visitations by the facility due to family not wanting a particular visitor to have access to R1. Based on interviews with Administrators Mark and Eleanor they have not allowed R1's visitor to enter the facility due to family not wanting them to visit. CONT on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
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-20230223080804
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: ELEONOR'S PLACE 2
FACILITY NUMBER: 306005866
VISIT DATE: 03/16/2023
NARRATIVE
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Based on interviews with Administrators they do not have any court order document on file that would exclude visitors from visiting R1. Based on interviews with 4 out of 6 residents stated they have not been denied visitations. The remaining residents were unable to be interviewed due to not being oriented to space and time and the other was unable to hear.

Based on the preponderance of evidence through interviews and observations the allegation that staff are prohibiting resident from having visitors is SUBSTANTIATED, meaning the complaint allegation was valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the Administrator.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
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
02/23/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230223080804

FACILITY NAME:ELEONOR'S PLACE 2FACILITY NUMBER:
306005866
ADMINISTRATOR:AVENDANO, DARYLLFACILITY TYPE:
740
ADDRESS:24772 ARGUS DRIVETELEPHONE:
(949) 547-5377
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
03/16/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Vangie Pablo- CaregiverTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff not providing residents medication as prescribed.
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Vangie Pablo, caregiver and explained the reason for the visit.

The department received a complaint on 02/23/2023 and the initial visit was conducted on 03/02/2023 by LPA Kimberly Lyman. LPA Lyman interviewed Administrators Mark Cruz and Eleanor Avenado and obtained copies of physician's report, emergency contact information and medication administration records for Resident 1 (R1). Regarding the allegation staff not providing residents medication as prescribed, the investigation revealed the following:

Per review of R1's medication, all medications are provided and signed off for the dates of Feb 1st to March 2nd. Based on observations the prescriptions are stored in bubble packs which as of 3/16/2023 medications were at the appropriate count for the month of March. CONT 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
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-20230223080804
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: ELEONOR'S PLACE 2
FACILITY NUMBER: 306005866
VISIT DATE: 03/16/2023
NARRATIVE
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Based on interviews with 4 out of 6 residents indicated they have never had issues not receiving their medications. The remaining residents were unable to be interviewed due to not being oriented to space and time and the other was unable to hear. Interviews with a resident's family indicated they have not witnessed any issues with medications.

Based on interviews with 4 out of 4 staff indicate that there have not been any issues with administering medications. All staff agreed they follow the medication administration record.

Based on the preponderance of evidence through record review, observation and interviews the allegation that staff not providing residents medication as prescribed is UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.This agency has investigated this complaint.
No deficiencies cited.

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

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230223080804
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: ELEONOR'S PLACE 2
FACILITY NUMBER: 306005866
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2023
Section Cited
CCR
87468.1(a)(11)
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a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: 11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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Administrator has since allowed visitations to all residents.
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This was not met as evidence by the facility did not allow R1 to have a visitor due to family's wishes withouth legal court order. This poses a potential risk to personal rights.
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5