306005980-3-28-2023-22-AS-SSAS-CQEU2Y-20230330151241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005980
Report Date: 03/28/2023
Date Signed: 03/28/2023 03:09:54 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
03/23/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230323151034

FACILITY NAME:	CARE VANNA		FACILITY NUMBER:	306005980
ADMINISTRATOR:	LESTER DEL ROSARIO		FACILITY TYPE:	740
ADDRESS:	2438 E PARKSIDE AVE		TELEPHONE:	(657) 224-9380
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 6	DATE:	03/28/2023
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Rio Valencia		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility retained a resident with a prohibited health condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made an unannounced complaint visit for the purpose to investigate into the above allegation. LPA was greeted by Caregivers Nelson Resoso and Rio Valencia and was granted entry after stating the purpose of the visit. At 11:42am, LPA spoke to Administrator (Admin) Karmian Calangi by telephone. During the course of the investigation, LPA met with Resident 1 (R1), interviewed Staff 1 (S1), and Admin Calangi, and copies of records were obtained pertinent to R1. The following was determined:

It was alleged that facility retained a resident with a prohibited health condition. On March 28, 2023, approximately 12:00pm, LPA met with R1 alongside S1 and observed a Gastrostomy feeding tube on R1's abdomen. Per review of records, R1 is not on hospice and is under the care of a home health agency. Per Title 22, 87616 Exceptions for Health Conditions, facility did not submit a written exception request to retain a resident with a prohibited health condition, therefore the preponderance has been met.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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-20230323151034

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: CARE VANNA	FACILITY NUMBER: 306005980
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/04/2023 Section Cited CCR 87616(a)	1 2 3 4 5 6 7	87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition...". This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to review Title 22 Regulation 87616 and to submit an Acknowledgement of Understanding in writing for the said regulation and to either place R1 on hospice or to submit a written exception request to LPA via email by POC due date.
	8 9 10 11 12 13 14	Based on observation, interviews, and record review, facility retained R1 with a G-tube which poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230323151034

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: CARE VANNA	FACILITY NUMBER: 306005980
	VISIT DATE: 03/28/2023

NARRATIVE

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Based on the observation, interviews, and the records reviewed, the above allegation is deemed SUBSTANTIATED. A deficiency is being cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See LIC9099D.

An exit interview was conducted with Administrator Karmian Calangi by telephone who consented Caregiver Rio Valencia to sign the report, and a copy of this report along with the LIC9099C, LIC811s, LIC9099D, and the appeal rights were provided during this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC9099 (FAS) - (06/04)

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