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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006150
Report Date: 06/13/2024
Date Signed: 06/13/2024 04:16:38 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
06/05/2024 and conducted by Evaluator Claudia Gutierrez
COMPLAINT CONTROL NUMBER: 22-AS-20240605174516
FACILITY NAME:CALIFORNIA CARE MENTAL HEALTHFACILITY NUMBER:
306006150
ADMINISTRATOR:BOUQUET, JASONFACILITY TYPE:
772
ADDRESS:25542 DANA MESA DRTELEPHONE:
(949) 291-3333
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Ruth CastilloTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility does not have the required medical assessments for clients.
Facility does not have the required treatment/rehabilitation plans for clients.
Facility did not complete the written needs and services plan within 72 hours of admission as required for clients.
The direct care staff at the facility are not properly trained.
INVESTIGATION FINDINGS:
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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Lead Behavioral Health Technician (BHT) Ruth Castillo and discussed the purpose of the inspection.

During the visit, LPA requested, obtained, and reviewed client records for four out of four current facility clients, which included the following documents: Physician Report (LIC 602), Admission Agreement, Needs and Services Plan, and Pre-appraisals. LPA also requested, obtained, and reviewed five direct care staff files.

Upon client record review, LPA observed that three out of four client files had incomplete or missing required medical assessments. LPA also determined facility does not have a completed Needs and Services plan for one out of four clients and Needs and Services Plan for four out of four current facility clients was not completed within 72 hours of admission as required by regulation. (Cont. LIC9099-C)
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
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 4
Control Number 22-AS-20240605174516
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: CALIFORNIA CARE MENTAL HEALTH
FACILITY NUMBER: 306006150
VISIT DATE: 06/13/2024
NARRATIVE
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Upon direct care staff file review, LPA observed three out of five direct care staff records did not contain a minimum of 20-clock-hours of continuing education per year, which shall provide the staff with the knowledge and skills as appropriate to their job assignment, as required by regulation.

Based on client and staff records review conducted, LPA determined that facility does not have the required medical assessments for clients, facility does not have the required treatment/rehabilitation plans for clients, and facility did not complete the written needs and services plan within 72 hours of admission as required for clients, and direct care staff at the facility are not properly trained. The preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations. (See LIC9099-D).

Program Director Bobby Santangelo was contact by phone and an exit interview was conducted with PD and BHT. A copy of this report, and appeal rights were left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20240605174516
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: CALIFORNIA CARE MENTAL HEALTH
FACILITY NUMBER: 306006150
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2024
Section Cited
CCR
81069(a)
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Prior to admitting a client into care or within 72 hours of admission, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidence by:
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PD stated medical assesments for clients would be completed immediately and a copy provided to LPA via email by POC date.
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Based on record review, the licensee did not comply with the section cited above in three of four client files, which poses an immediate health and safety 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: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20240605174516
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: CALIFORNIA CARE MENTAL HEALTH
FACILITY NUMBER: 306006150
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2024
Section Cited
CCR
81068.2(b)
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For each client admitted, the licensee shall ensure that a written Needs and Services Plan is started prior to admission, and completed prior to or within 72 hours of admission.

This requirement is not met as evidence by:
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Program Director stated training would be conducted with appropriate staff to ensure Needs and Services plans are completed prior to or within 72 hours. PD will provide with proof via emai by POC date.
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Based on record review, the licensee did not comply with the section cited above as one of four client's Needs and Services Plan was incomplete and four of four client Needs and Services Plans were not completed within 72 hours, which poses a potential health and safety risk to persons in care.
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Type B
07/12/2024
Section Cited
CCR
81065(r)
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All direct care staff shall receive a minimum of 20-clock-hours of continuing education per year, which shall provide the staff with the knowledge and skills as appropriate to their job assignment.

This requirement is not met as evidence by:
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PD stated direct care staff will receive training immeidately. PD stated proof will be provided to LPA via email by POC date.
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Based on record review, the licensee did not comply with the section cited above in three out of five staff files which poses a potential health and safety 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: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4