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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006150
Report Date: 09/04/2024
Date Signed: 09/04/2024 10:59:02 AM

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
PUBLIC
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: 2DATE:
09/04/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Hayley MontesTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Facility does not have signed admission agreements for clients.
The direct care staff at the facility do not meet the minimum requirements to work at the facility.
INVESTIGATION FINDINGS:
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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Behavioral Health Technician (BHT) Hayley Montes and discussed the purpose of the inspection.

Upon record review, LPA observed four client files had signed admission agreements, and admission agreements were signed by each client, however, one of four admission agreements was not signed by client’s authorized representative.

Upon direct care staff file review, LPA observed two of five direct care staff records did not indicate staff have a minimum of one year of full-time experience, or its part-time equivalent, working in a program serving persons with mental disabilities and the program did not document a specific plan of supervision and in-service training for the employee which will guarantee the ongoing qualification of the employee to perform the job.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
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 3
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: 09/04/2024
NARRATIVE
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Based on client and staff records review conducted, LPA determined that facility does not have signed admission agreements for clients and the direct care staff at the facility do not meet the minimum requirements to work at the facility. 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 (PD) Bobby Santangelo was contacted by phone at 10:12 a.m., an exit interview was conducted and 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: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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: 09/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
81065(n)
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All direct care staff shall meet the minimum qualifications as set forth in California Code of Regulations, Title 9, Division 1, Chapter 3, Article 3.5, Sections 532.6(h) and (i).

This requirement is not met as evidence by:
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PD stated a written plan of action to ensure compliance with regulation will be submitted to LPA via email by POC date.
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Based on observation, the Licensee did not comply with section cited above in two of five direct care staff records, which poses a potential health, safety, and personal rights risk to persons in care.
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Type B
10/04/2024
Section Cited
CCR
81068(a)
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The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidence by:
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LPA verified client's admission agreement has been signed by authorized representative, and PD stated a written plan of action to ensure compliance with regulation will be submitted to LPA via email by POC date.
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Based on observation, the Licensee did not comply with section cited above in one of five client records, which poses a potential health, safety, and 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: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3