306005986-12-19-2022-22-AS-AJLO-CMJUUL-20221228145345

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005986
Report Date: 12/19/2022
Date Signed: 12/19/2022 12:13:03 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
12/13/2022 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221213153906

FACILITY NAME:	ACTIVCARE LAGUNA HILLS		FACILITY NUMBER:	306005986
ADMINISTRATOR:	SHETTER, TODD A.		FACILITY TYPE:	740
ADDRESS:	25200 PASEO DE ALICIA		TELEPHONE:	(858) 565-4424
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	72	CENSUS: 32	DATE:	12/19/2022
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Patricia Miller, Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility failed to report active COVID cases.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez visit the facility to conduct the initial 10 day visit to investigate the above mentioned complaint allegation. LPA arrived at the facility was greeted by the receptionist and granted entry. LPA met with Patricia Miller, Executive Director and explained the nature of the visit.

Findings are based upon this investigation which included interview conducted and tour of the physical plant of the facility.

It is alleged that facility failed to report active covid cases. Interview conducted with S1 revealed that facility had a single case of covid on December 06, 2022. S1 indicated individual who tested positive notified the facility on December 06, 2022 of covid test results and did not return to the facility until December 18, 2022 once they were cleared.
Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022

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-20221213153906

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ACTIVCARE LAGUNA HILLS	FACILITY NUMBER: 306005986
	VISIT DATE: 12/19/2022

NARRATIVE

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During the visit, LPA toured the physical plant of the facility and observed the following: Facility is following covid screening guidelines and LPA observed the screening station in the entrance of the facility located in the front desk. Staff were observed to be wearing face mask and hand sanitizer placed throughout the facility.

Facility had one covid case starting on 12/06/2022 and no other cases since. Case was not reported to Licensing or Public Health, of which department learned of the case. Facility Executive Director did not follow proper notification procedures and was reported to LPA on today’s visit after LPA made contact with facility.

During the course of the investigation, there was sufficient evidence to substantiate the allegation of facility failed to report active covid cases. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. See LIC9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Executive Director and a copy of this LIC9099 and LIC9099-D, along with a copy of the appeal rights was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20221213153906

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ACTIVCARE LAGUNA HILLS	FACILITY NUMBER: 306005986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/19/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/26/2022 Section Cited CCR 87211(a)(2)	1 2 3 4 5 6 7	Each licensee shall furnish to the licensing agency such reports... including, but not limited to, the following: Occurrences, such as epidemic outbreaks.. which threaten the welfare, safety or health of residents.., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when	1 2 3 4 5 6 7	Executive Director to forward a statement of understanding regarding reporting requirements and forward to LPA by POC due date.
	8 9 10 11 12 13 14	appropriate. Based on interview conducted, Executive Director failed to ensure covid case was reported to Licensing or Public Health. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	At the time of visit LPA received the statement from Executive Director and the department covid reporting script.
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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.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022

LIC9099 (FAS) - (06/04)

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