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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006363
Report Date: 10/30/2024
Date Signed: 10/30/2024 04:20:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
08/13/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20240813114923
FACILITY NAME:QUEENS HOME 3FACILITY NUMBER:
306006363
ADMINISTRATOR:MAGHBOULEH, KATHYFACILITY TYPE:
740
ADDRESS:14752 HOLT AVETELEPHONE:
(714) 731-6385
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:15CENSUS: 8DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:TIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Facility did not provide resident records to legal representative.
INVESTIGATION FINDINGS:
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This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by facility staff. LPA met with Arya , Administrator and explained the nature of the inspection.

The department received a complaint on 8/13/2024 stating Facility did not provide resident redcords to legal representative. During the investigation, the department interviewed the Administrator (AD) and staff.

On 8/23/2024 LPA conducted a visit to the facility. LPA obtained copies of the staff roster dated May 2024, resident roster dated 7/24/24, HIPAA complaint release letter dated August 8, 2024, FedEx Delivery shipping slip dated August 13, 2024 and electronic copies of all the records the facility has on file for R1 and a forwarded email containing a record request fulfilled by the facility.
(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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-20240813114923
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: QUEENS HOME 3
FACILITY NUMBER: 306006363
VISIT DATE: 10/30/2024
NARRATIVE
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(continued from LIC9099)

Based on review of FedEx shipping/delivery labels, LPA determined the HIPAA letter was sent to the facility from R1's legal representative's office on 8/8/24 and that it was delivered to the facility on Saturday, 8/10/24.

LPA conducted interviews with one staff (S1), Licensee(L1) and Administrator(AD). AD, and L stated the request was received on 8/13/2024, they communicated with LR's office on 8/14/24 and the request was fulfilled on 8/16/2024. AD, L1 and S1 stated AD and L1 would have been the only staff to open the package sent from R1's legal representative. AD, L1 and S1 also stated, AD and L don't work in the facility over the weekends.

LPA reviewed an email sent to R1's legal representative's office. The email was dated 8/16/2024 with a 55-page pdf attachment with the documents requested for R1. LPA determined the facility fulfilled R1's legal representative's request on 8/16/2024.

Per Health and Safety Code 1569.269(a) "Residents of residential care facilities for the elderly shall have all of the following rights: (21) To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies."

Based on interviews conducted and records reviewed, the facility did not comply with the regulation stated above due to the facility exceeding two business days to fulfill the request.

The preponderance of evidence standard has been met. The allegation is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240813114923
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: QUEENS HOME 3
FACILITY NUMBER: 306006363
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
HSC
1569.269(a)
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1569.269(a) Residents of residential care facilities for the elderly shall have all of the following rights: (21) To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days,
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The facility fulfilled the request on August 16, 2024, therefore the plan of correction has been fulfilled before the time of this visit. LPA provided a clear letter with this deficiency.
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at a cost not to exceed the community standard for photocopies.

The licensee did not comply with the section cited above because the investigation revealed, the facility exceeded two days to get the requested documents sent out.
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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: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3