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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366423605
Report Date: 06/03/2024
Date Signed: 06/03/2024 12:30:06 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2024 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240530125539
FACILITY NAME:SALEM CHRISTIAN HOMES-YORBA HOMEFACILITY NUMBER:
366423605
ADMINISTRATOR:MARGARET ZWARTFACILITY TYPE:
740
ADDRESS:12420 YORBA AVETELEPHONE:
(909) 627-5774
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:6CENSUS: 6DATE:
06/03/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Justine Guillen, Administrator TIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Licensee is operating beyond the scope of license.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with administrator Justine Guillen and explained the elements of the complaint.

Regarding the allegation that licensee is operating beyond the scope of licensee; The allegation is related to the number of Hospice Waiver and it's capacity. The facility is approved for one (1) Hospice and the facility is currently providing hospice service to two (2) clients in care. Files were reviewed for resident #1 (R1) and R2 and confirm that each resident is on hospice and being provided service from a hospice agency.

***continued in LIC 9099C***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
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 56-AS-20240530125539
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: SALEM CHRISTIAN HOMES-YORBA HOME
FACILITY NUMBER: 366423605
VISIT DATE: 06/03/2024
NARRATIVE
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Based on LPA observations, interviews which were conducted and records review, the preponderance of evidence standard has been met. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division) are being cited on the attached LIC 9099D).

This report was signed by LPA Prieto and administrator Guillen and a copy of this report was left with the facility along with the appeal rights.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240530125539
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SALEM CHRISTIAN HOMES-YORBA HOME
FACILITY NUMBER: 366423605
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2024
Section Cited
CCR
87632
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Hospice Care Waiver -(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility.
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Licensee to submit hospice waiver to CCLD LPA by POC date. Waiver to be submitted to LPA via mail or fax
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Faclity has a hospice waiver for one (1) and currently has two (2) clients on hospice 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.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3