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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004650
Report Date: 09/16/2021
Date Signed: 09/16/2021 10:55:07 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2021 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 25-AS-20210616122042

FACILITY NAME:BUENA VISTA HOME IIFACILITY NUMBER:
347004650
ADMINISTRATOR:ASTRONOMO, REYFACILITY TYPE:
735
ADDRESS:6350 MARIPOSA AVENUETELEPHONE:
(916) 727-7273
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:4CENSUS: 4DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Melody Bulanadi, CaregiverTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Resident was left in a soiled diaper for a long period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegations listed above. LPA met with Melody Bulanadi and spoke with Administrator Rey Astronomo over the phone.
LPA investigated allegation, "Resident was left in a soiled diaper for a long period of time". LPA interviewed relevant party in which they stated C2 is soaked in urine when they wake up in the mornings. Relevant party sent pictures which appear to show C2 in bed with liquid stains on sheets. LPA interviewed caregivers in which they stated C2 requires continence care, and they transfer C2 to the toilet throughout the day and change C2's depend through the day and night. Caregivers stated C2 is checked every 2 hours throughout the night and they do not find C2 soaked in urine in the mornings. Per physician report C2 is nonverbal and LPA was unable to interview client.
continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 25-AS-20210616122042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: BUENA VISTA HOME II
FACILITY NUMBER: 347004650
VISIT DATE: 09/16/2021
NARRATIVE
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LPA reviewed C2's IPP in which it states client requires assistances with continence care and staff to check on client every 2-3 hours. Due to the conflicting information, LPA finds allegation to be UNSUBSTANTIATED.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4