306005869-9-2-2022-22-AS-AORZ-CL2UQ5-20221110144632

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005869
Report Date: 09/02/2022
Date Signed: 09/02/2022 01:43:23 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
08/26/2022 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220826142342

FACILITY NAME:	JJ ASSISTANCE HOME CARE		FACILITY NUMBER:	306005869
ADMINISTRATOR:	AZIZA, SIMONA		FACILITY TYPE:	740
ADDRESS:	23712 CORONEL DR		TELEPHONE:	(949) 587-1595
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	09/02/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Simona Aziza, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility failed to report an active COVID outbreak.

INVESTIGATION FINDINGS:

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At approximately 10:30am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced inspection for the purpose of investigating the above allegation. LPA was greeted by caregivers Henry and Aurora Magbiray and explained the purpose of the visit. Administrator Simona Aziza was notified of the visit by telephone and arrived around 11:15am to assist with the visit. The listed allegation was provided to the facility representative.

Regarding the allegation that facility failed to report a COVID outbreak, the following are the findings. Resident R1 exhibited symptoms of COVID on or around 08/20/2022, including a fever and tested positive on the same day. Further testing performed by the facility on staff and residents yielded additional positive resuts. In total, 4 residents and 2 members of staff tested positive, which the facility failed to report as required by section 87211(a)(2) of the California Code of Regulations.

CONTINUED ON FORM LIC9099-C

Substantiated

Estimated Days of Completion: d

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

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-20220826142342

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: JJ ASSISTANCE HOME CARE	FACILITY NUMBER: 306005869
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/03/2022 Section Cited CCR 87211(a)(2)	1 2 3 4 5 6 7	Section 87211(a)(2) of the California Code of Regulations indicates that: Occurrences, such as epidemic outbreaks, (...) which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours (...) to the licensing agency (...). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee provided local Public Health with information on the outbreak on 09/02/2022. Licensing Program Analyst Kevin Saborit-Guasch provided a consultation on the reporting requirements applicable to the facility and provided licensee with the script used by the Department as well as form LIC624.
	8 9 10 11 12 13 14	Facility failed to report a COVID-19 outbreak involving both members of staff as well as four (4) residents that occured on or around 08/20/2022. This poses a potential risk to the health and safety of individuals in care.	8 9 10 11 12 13 14	Licensee will provide LPA with the requested information within 24 hours.
	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) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220826142342

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: JJ ASSISTANCE HOME CARE	FACILITY NUMBER: 306005869
	VISIT DATE: 09/02/2022

NARRATIVE

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CONTINUED FROM FORM LIC9099-C

One of the positive cases is noted to have resulted in a 911 call made by the family. Resident was briefly admitted to Saddleback Hospital but was rapidly released into a Skilled Nursing Facility before returning to the facility on 08/31/2022.

All other residents and staff are documented to have either been asymptomatic or have only displayed mild symptoms. Mass testing performed at the facility gave negative results for all parties involved on 08/25/2022 or 08/26/2022. LPA was able to observe that all residents present in the facility appear well taken care of.

Based on LPA's record review, observations and conducted interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being issued in regard to the reporting requirements for the facility. An exit interview was conducted and a copy of this report along with appeal rights was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC9099 (FAS) - (06/04)

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