306005869-7-31-2024-22-AS-SSAS-D7S28A-20240802170959

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005869
Report Date: 07/31/2024
Date Signed: 07/31/2024 04:51:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
07/01/2024 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240701134947

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:	DATE:	07/31/2024
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Simona Aziz, administrator (via telephone)		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility did not provide medical attention in a timely manner

Facility did not report a resident's change of condition to their responsible party

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the two allegations listed above. LPA was greeted and granted entry by facility staff after stating the purpose of the visit. Administrator Simona Aziz was notified via telephone and presented the findings remotely before authorizing facility staff to sign the report on her behalf.

An initial complaint investigation visit was conducted on July 10, 2024. LPA requested resident records for former facility resident R1 which were provided via email as follows: admission agreement/ identification form, physician report, hospice plan of care. Copies of text message exchanges with the resident's daughter, hospice staff and responsible party were also provided during and briefly after the visit. LPA conducted an interview with facility administrator and two facility staff during the visit. Additional witness interviews were conducted via telephone at a later time.
CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

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-20240701134947

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JJ ASSISTANCE HOME CARE	FACILITY NUMBER: 306005869
	VISIT DATE: 07/31/2024

NARRATIVE

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CONTINUED FROM FORM LIC9099
Regarding the allegation that Facility did not provide medical attention in a timely manner, the following has been concluded: Based on interviews conducted as well as resident and hospice records, resident R1 was admitted on March 2nd, 2024 to the facility with hospice care already in place for a documented terminal diagnosis of Senile degeneration of the brain, Unspecified. The resident was discharged on April 11, 2024 after having been transferred to the hospital and never returned to the facility. During the duration of R1's admission, frequent and ongoing interventions by hospice staff were documented as well as evidence of a call to 911 when the resident's condition appeared to warrant a transfer to the Emergency Department. There was no evidence of any deficiency from the facility in facilitating R1's access to medical resources as needed by his condition. The allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred.

Regarding the allegation that Facility did not report a resident's change of condition to their responsible party, the following has been concluded: Based on interviews and copies of text messages exchanged with R1's daughter, there does not appear to have been any lapses in communication regarding R1's condition. Items such as physical therapy, supplemental nutrition, eating habits and levels of consciousness were discussed frequently verbally and via text messages during R1's period of admission. Multiple attempts were also made to interview R1's partner and responsible party as documented on the admission agreement, none of which successful. As a result, the allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred.

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

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC9099 (FAS) - (06/04)

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