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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300611830
Report Date: 04/28/2023
Date Signed: 04/28/2023 03:21:07 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
04/25/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230425133150
FACILITY NAME:CAMBRIDGE HOUSEFACILITY NUMBER:
300611830
ADMINISTRATOR:EVELYN WALLACEFACILITY TYPE:
740
ADDRESS:1895 NORTH CAMBRIDGETELEPHONE:
(714) 637-3911
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:6CENSUS: 5DATE:
04/28/2023
UNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Evelyn Wallace - Administrator TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff refuse resident to have visits
INVESTIGATION FINDINGS:
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On this Day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Caregiver Ray Villanueva. Administrator Evelyn Wallace arrived shortly after.

The department received a complaint on 04/25/2023 and initial 10 day visit was conducted on 4/28/2023. During the course of the investigation LPA Mendivil obtained copies of the following: admission agreement and house rules. Regarding the allegation staff refuse resident to have visits, the investigation revealed the following:

Based on interviews with Administrator Evelyn Wallace the facility policy for visitation is to allow visitors from 9 am to 7pm with exceptions for end of life or hospice. Administrator Evelyn stated all residents and/or responsible parties have signed admission agreement and personal rights document, which outlines residents' personal rights to visitations. CONT on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
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-20230425133150
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: CAMBRIDGE HOUSE
FACILITY NUMBER: 300611830
VISIT DATE: 04/28/2023
NARRATIVE
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Administrator acknowledges has not allowed a visitor for Resident 1 (R1) due to family has told the facility to not allow a specific visitor. Based on interviews with Administrator she does not have any court order document on file that would exclude visitors from visiting R1. LPA was unable to conduct interviews with residents as 2 residents did not wish to be interviewed and the remaining 2 were unable to be interviewed. Interview conducted with 1 resident indicated their family visits almost every day.

Based on the preponderance of evidence through interviews and observations the allegation that Staff refuse resident to have visits is SUBSTANTIATED, meaning the complaint allegation was valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the Administrator.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230425133150
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: CAMBRIDGE HOUSE
FACILITY NUMBER: 300611830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/04/2023
Section Cited
CCR
87468.1(a)(11)
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a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: 11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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Administrator will allow visitors and remind families of Title 22.
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This requirement was not met as evidence by Administrator stated they have not let R1's family member visit on 2 occasions. This poses a risk to personal rights.
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3