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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006116
Report Date: 09/14/2023
Date Signed: 09/14/2023 02:46:57 PM

Unfounded


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
08/23/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230823105523
FACILITY NAME:FLOWERS FAMILY CAREFACILITY NUMBER:
306006116
ADMINISTRATOR:MARTINEZ, JONATHANFACILITY TYPE:
740
ADDRESS:1009 W 20TH ST.TELEPHONE:
(949) 274-0634
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY:6CENSUS: 3DATE:
09/14/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Dominga Santillian and Jonathan MartinezTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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-Facility staff is not providing residents with showers and or baths
-Facility does not have a fire clearance
-Facility does not have a business license
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Jonathan Martinez arrived during the visit.
During the course of the investigation, LPA toured the facility and interviewed staff, residents and witnesses. Regarding the allegations that facility does not have a business license, facility does not have a fire clearance and facility staff is not providing residents with showers and or baths, the investigation revealed the following: Department regulations do not require facilities to obtain a business license from the city of operation. Facility obtained a fire clearance on 02/11/2022 for capacity of five non-ambulatory residents and one bedridden resident. Facility floor plan or clearance has not changed since that time. During the investigation, LPA interviewed three residents and three staff. All interviewed confirm residents are receiving showers on a regular basis. Therefore, the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was emailed to Administrator.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
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
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
08/23/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230823105523

FACILITY NAME:FLOWERS FAMILY CAREFACILITY NUMBER:
306006116
ADMINISTRATOR:MARTINEZ, JONATHANFACILITY TYPE:
740
ADDRESS:1009 W 20TH ST.TELEPHONE:
(949) 274-0634
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY:6CENSUS: 3DATE:
09/14/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Dominga Santillian and Jonathan MartinezTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
-Facility does not have sufficient staff to meet the residents needs
-Facility is not following medical orders
-Facility is not providing residents with nutritious meals
-Facility is not providing activities for the residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Jonathan Martinez arrived during the visit.
During the course of the investigation, LPA toured the facility and interviewed staff, residents and witnesses. Regarding the allegations that facility does not have sufficient staff to meet the residents needs, facility is not following medical orders, facility is not providing residents with nutritious meals, and facility is not providing activities for the residents, the investigation revealed the following: Facility has two live in caregivers and one reliever. Administrator states being back up for caregiving. Facility staff indicate Administrator is available and responsive by phone 24 hours a day. LPA observed all residents in need of wheelchairs had wheelchairs provided for them. During two different visits, LPA observed ample fresh food supply including fruit, vegetables and chicken. LPA observed games in the facility. LPA interviewed all residents residing in the facility and all CONTINUED ON LIC 9099C DATED 09/14/2023
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20230823105523
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: FLOWERS FAMILY CARE
FACILITY NUMBER: 306006116
VISIT DATE: 09/14/2023
NARRATIVE
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denied any willingness to participate in facility activities. Due to conflicting information, LPA is unable to corroborate allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/23/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230823105523

FACILITY NAME:FLOWERS FAMILY CAREFACILITY NUMBER:
306006116
ADMINISTRATOR:MARTINEZ, JONATHANFACILITY TYPE:
740
ADDRESS:1009 W 20TH ST.TELEPHONE:
(949) 274-0634
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY:6CENSUS: 3DATE:
09/14/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Dominga Santillian and Jonathan MartinezTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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2
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9
-Administrator is not present at the facility sufficient amount of hours
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Jonathan Martinez arrived during the visit.
During the course of the investigation, LPA toured the facility and interviewed staff, residents and witnesses. Regarding the allegations that administrator is not present at the facility sufficient amount of hours, the investigation revealed the following: Per interviews conducted, Administrator is on-site a couple days a week between 30-120 minutes. LPA observed personnel files are incomplete. Facility has two live in caregivers and one reliever only making it imperative that Administrator is present at the facility a sufficient amount of hours to ensure all aspects of facility operation are running smoothly and residents are properly cared for. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was emailed to facility administrator along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230823105523
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: FLOWERS FAMILY CARE
FACILITY NUMBER: 306006116
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited
CCR
87405(a)
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All facilities shall have a qualified and currently certified administrator.. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours.. This requirement is not being met as evidenced by:
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Licensee to forward an updated LIC 500 with additional verifiable hours to be worked at the facility. Licensee to forward proof by POC due date.
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Based on interviews conducted, Administrator failed to ensure that administrator coverage is sufficient for running the facility effectively. This poses a potential health and safety risk to residents 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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5