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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006143
Report Date: 11/16/2023
Date Signed: 11/16/2023 02:40:33 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
11/14/2023 and conducted by Evaluator Jessica Cho
COMPLAINT CONTROL NUMBER: 22-AS-20231114134548

FACILITY NAME:MENTAL HEALTH COLLECTIVE, THEFACILITY NUMBER:
306006143
ADMINISTRATOR:ROSENBAUM, GREGORYFACILITY TYPE:
772
ADDRESS:519 SANTA ANA AVE.TELEPHONE:
(888) 717-9555
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY:6CENSUS: 3DATE:
11/16/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Gregory Rosenbaum- Administrator
Catherine Mann- Compliance Director		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility failed to follow their own discharge procedures.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose to conduct a complaint investigation into the above allegation. LPA observed the facility was vacant and made several attempts by telephone to make contact with a facility representative. At 9:42am, LPA made contact with Administrator (Admin) Gregory Rosenbaum by telephone, and Compliance Director (CD) arrived at the facility at 10:04am. LPA was allowed entry accompanied by CD and initiated the investigation approximately 10:10am. Today's census is three. LPA observed no clients present during the time of the visit. LPA conducted an interview with staff and obtained copies of pertinent documentations of (6) clients and (4) staff including facility records and conducted an interview with staff. The following was determined based on the review of records and interview:

It is alleged that the facility failed to follow their own discharge procedures. In review of three out of the three closed client records, facility did not have the discharge summary for one out of the three clients.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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-20231114134548
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: MENTAL HEALTH COLLECTIVE, THE
FACILITY NUMBER: 306006143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2023
Section Cited
CCR
81022(j)
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81022 Plan of Operation (j) The facility shall operate in accordance with the terms specified in the plan of operation and may be cited for not doing so.
This requirement was not met as evidenced by:
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Administrator stated that they will provide a proof of staff training and submit an Acknowlegement of Understanding for the said deficiency to LPA by POC due date.
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Based on LPA's interview and review of records, facility did not complete a discharge summary as documented per the facility's plan of operation for one out of the three clients that were discharged which poses a potential Health, Safety, or Personal Rights risk to persons 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: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20231114134548
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: MENTAL HEALTH COLLECTIVE, THE
FACILITY NUMBER: 306006143
VISIT DATE: 11/16/2023
NARRATIVE
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One out of one facility staff indicated during the interview that the facility did not have the discharge summary for Client #1 (C1), therefore facility is not in compliance as documented per their plan of operation which states that "a discharge summary is completed and reviewed with the resident as the resident is set to be discharged or prior to discharge from the program."

Based on LPA's interview which was conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility failed to follow their own discharge procedures is deemed SUBSTANTIATED per the California Code of Regulations, Title 22, Division 6, Chapter 2. A deficiency is being cited on the attached LIC 9099-D.

An exit interview was conducted with Adminstrator Gregory Rosenbaum and Compliance Director Catherine Mann, and a copy of this report along with the LIC9099-C, LIC9099-D, LIC-811, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5