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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006073
Report Date: 12/05/2022
Date Signed: 12/05/2022 12:26:04 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
10/10/2022 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221010165215
FACILITY NAME:EDEN BY ENHANCEFACILITY NUMBER:
306006073
ADMINISTRATOR:KHOUIE, CHRISTINAFACILITY TYPE:
772
ADDRESS:35 MANN STREETTELEPHONE:
(714) 475-7013
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:6CENSUS: 5DATE:
12/05/2022
UNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Clinical Director-Melody FathiTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility staff did not accord dignity and respect to clients.
Facility did not report client absence to the Licensing Agency.
Facility admitted client with prohibited health condition.
Facility did not provide a safe and comfortable environment for clients in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility for the purpose of delivering the findings for this complaint received on 10/10/22. LPA De Perio was greeted and granted entry by staff on duty, and LPA De Perio met with Clinical Director (CD) Melody Fathi.

For this visit, there were a total of 2 staff on duty (Clinical Director and Operations Manager) and a total of 5 clients in care.

This agency has investigated the complaint alleging that facility staff did not accord dignity and respect to clients. Upon conducting interviews, staff informed LPA De Perio that staff would send pictures and videos of individuals from the internet mimicking the physical appearance of, and behaviors of the clients in care. It was also reported that staff would also send pictures of the actual clients, therefore, violating the confidentially of the clients in care.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 22-AS-20221010165215
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: EDEN BY ENHANCE
FACILITY NUMBER: 306006073
VISIT DATE: 12/05/2022
NARRATIVE
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LPA De Perio also reviewed additional documents of comments being made directing to clients. Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

This agency has investigated the complaint alleging that facility did not report client absence to the Licensing Agency. On the 10-day visit conducted on 10/17/22, upon conducting interviews with staff, all staff interviewed admitted that clients have AWOL’d but did not report it to Licensing. Per Community Care Licensing records, there were no reports that were made nor received (via verbal or written), regarding clients missing from the facility. Per facility Plan of Operations, page 31, “X. NEEDS AND SERVICE PLAN” it states, on section 10) iv. “The administrator will file an Incident Report with Community Care Licensing”. On page 60, “XXIII. SPECIAL INCIDENCE REPORT (SIR)” it states, “Eden by Enhance will report the following special incidents if they occurred during the time the consumer was receiving services within the facility: (A) The consumer is missing, and the facility has filed a missing person’s report with a law enforcement agency” and “(c) The report shall be submitted to the Community Care Licensing Division having case management responsibility for the consumer. (f) The facility reports to the Community Care Licensing Division” Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

This agency has investigated the complaint alleging that facility admitted client with prohibited health condition. Upon record review and interviews, staff members informed the licensee that a client would not be appropriate for program due to client recently getting a tracheostomy and having a stomach tube. Per interviews, licensee stated that despite consultations with the clinical staff, licensee has the “last say with everything”. Based on LPAs observations and interviews which were conducted and record review, preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20221010165215
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: EDEN BY ENHANCE
FACILITY NUMBER: 306006073
VISIT DATE: 12/05/2022
NARRATIVE
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This agency has investigated the complaint alleging that facility did not provide a safe and comfortable environment for clients in care. Per interviews and record reviews conducted, facility failed to ensure that environment was safe and comfortable for all clients in care. Behavioral contracts were implemented by clinical director present at the time, however, staff continued to express concerns about the safety and well-being of the remaining residing clients, facility did not take the proper and additional measures to ensure that all clients were accorded a safe and comfortable living environment. Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

For today's visit, citations were issued per Title 22 Division 6 of the California Code of Regulations.

LPA De Perio conducted an exit interview with CD Fathi and copy of this report and LIC9099-D's was left in this facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20221010165215
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: EDEN BY ENHANCE
FACILITY NUMBER: 306006073
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2022
Section Cited
CCR
81072(1)
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81072 Personal Rights
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by:
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As plan of correction, facility will provide training to staff regarding regulation cited and will provide proof to Community Care Licensing and assigned LPA on or by 12/19/22.
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Based on review of docuemnts, and interviews, facility failed to accord dignity of clients by sending pictures and videos that mimicked the physical appearance of, and behaviors of the clients in care.
This poses a potential threat on the health safety of clients in care.
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Type B
12/05/2022
Section Cited
CCR
81061(b)(E)
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81061 Reporting Requirements
(b) …A report shall be made...submitted to the licensing agency...
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
This requirement is not met as evidenced by:
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As plan of correction, facility will provide training to staff regarding regulation cited and will provide proof to Community Care Licensing and assigned LPA on or by 12/19/22.
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Based on review of documents, and interviews, facility failed to report to licensing regarding an incident of client AWOLing. During the interviews conducted, staff provided direct admission that no reports were completed nor submitted.
This poses a potential health and safety of clients in care.
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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.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20221010165215
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: EDEN BY ENHANCE
FACILITY NUMBER: 306006073
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2022
Section Cited
CCR
81092.11(1)(2)
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81092.11 Tracheostomies
(1) Licensee is in compliance with Section 81092.1.
(2) ...Client is mentally and physically capable of providing all care…opening (stoma)...is completely healed...
This requirement is not met as evidence by:
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As plan of correction, facility will provide training to staff regarding regulation cited, along with regulation 81092 Restricted Health Conditions and will provide proof to Community Care Licensing and assigned LPA on or by 12/19/22.
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Based on record review, and interviews, facilty failed to ensure that the client is mentally and physically capable of providing care... Based on record review, per biopsychosocial assessment, client (C1) experiences suicidality, self-harms and has a history of substance abuse.
This poses a potential health and safety risk to clients in care.
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Type B
12/05/2022
Section Cited
CCR
81072(2)(3)
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81072 Personal Rights
(2) To be accorded safe, healthful and comfortable accommodations…
(3) To be free from… intimidation... or other actions of a punitive nature...interference with the daily living functions...
This requirement is not met as evidence by:
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As plan of correction, facility will provide training to staff regarding regulation citated, and will provide proof to Community Care Licensing and assigned LPA on or by 12/19/22.
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Based on record reviews and interviews, facility failed to ensure that clients were accorded safe...accommodations. It was revealed that client 2 (C2) was placed on numerous behavioral contracts due to inappropriate behaviors, however facility failed to discharge C2 accordingly.
This poses a potential health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5