306006054-10-3-2022-22-AS-SSAS-CMU54L-20230106183743

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006054
Report Date: 09/06/2022
Date Signed: 10/03/2022 10:21:48 AM

Unsubstantiated

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
08/30/2022 and conducted by Evaluator Claudia Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220830132833

FACILITY NAME:	PAGEANTRY COTTAGE, THE		FACILITY NUMBER:	306006054
ADMINISTRATOR:	JABONERO, MACRINA		FACILITY TYPE:	740
ADDRESS:	125 PAGEANTRY DR		TELEPHONE:	(714) 504-5371
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 6	DATE:	09/06/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Edna Tamondong Macrina Jabanero		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not seek medical attention in a timely manner.

Resident call bell not operational.

Resident sleeping in common room.

INVESTIGATION FINDINGS:

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This is an amended report.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with staff Julius Dinglasa and took a guided tour of the facility. Facility Owner (FO) Edna Tomondong arrived at 10 a.m. Administrator (AD) Macrina Jabanero arrived at 10:36 a.m.

Complaint alleges staff did not seek medical attention in a timely manner, resident call bell not operational and resident sleeping in common room.

Interviews were conducted with FO and AD regarding the allegation of not seeking medical attention in a timely manner. FO stated that Resident 1 (R1) is able to check their blood sugar levels and administer their own insulin with the “hand over hand” method. On 8/18/22 R1 had an elevated blood sugar level of 474, physician and family were contacted by phone. Per R1’s insulin log dated 8/18/22 and 8/19/22, insulin was administered, blood sugar levels were monitored and began to stabilize. (Cont. LIC9099-C)

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

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-20220830132833

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: PAGEANTRY COTTAGE, THE	FACILITY NUMBER: 306006054
	VISIT DATE: 09/06/2022

NARRATIVE

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Interviews were conducted with FO and AD regarding residents’ call bells. AD stated residents’ call bells have always been operable. FO stated the call bells have been operable and continue to be operable. LPA tested the call bells for R1 and R3, call bells were found to be operable with an audible alarm. Interviews were conducted with R1 and R2 who stated they had a pendant that alerted staff for help, and both denied the pendant was ever broken or inoperable.

Interviews were conducted with FO and AD who deny any resident sleeping in a common room at any time. LPA observed common areas to be free of debris and bedding. The facility currently has 5 residents in care, each was observed to have a single, non-shared bedroom. Interviews were also conducted with R1 and R2 who denied having been relocated or sleeping in a common room. Interviews were also conducted with S1 and S2 who denied any resident sleeping in a common room at any time.

LPA attempted to contact Report Party (RP). Due to RP not returning phone calls to confirm, deny, or provide additional information regarding allegations LPA is unable to determine if staff did not seek medical attention in a timely manner, if resident call bell was not operational, or if resident was sleeping in common room.

Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore at this time the above allegation is unsubstantiated.

An exit was conducted with FO and AD. A copy of this report was provided at the end of the visit.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC9099 (FAS) - (06/04)

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