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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001102
Report Date: 01/24/2023
Date Signed: 01/24/2023 11:47:08 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, 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
01/19/2023 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230119145353
FACILITY NAME:JASMIN'S CARE HOMEFACILITY NUMBER:
306001102
ADMINISTRATOR:MANUEL G. PEREZFACILITY TYPE:
740
ADDRESS:2817 SAN JUAN LANETELEPHONE:
(714) 662-0625
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 4DATE:
01/24/2023
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Manual Perez - AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility staff physically abused resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced initial 10 day complaint visit to initiate the investigation into the above allegation as well as to deliver the findings of the investigation. LPA Velazquez was allowed entry into the facility and met with Administrator Manuel Perez.

On today's visit LPA Velazquez conducted interviews with residents and staff. LPA also reviewed and obtained copies of facility, resident, and staff records. During the course of the investigation the following was revealed: LPA Patricia Velazquez conducted interviews with residents and staff. Six of six individuals interviewed could not corroborate the above allegation. LPA Velazquez also reviewed facility, resident, and staff records. The records reviewed included Physician's Reports, Resident Appraisals, Appraisal Needs and Services Plans, Centrally Stored Medication and Destruction Records (CSMDRs), Resident (R) #1's discharge documents from Hoag Hospital Newport where R1 was hospitalized from January 16, 2023 until discharge on January 20, 2023,
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
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 2
Control Number 22-AS-20230119145353
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: JASMIN'S CARE HOME
FACILITY NUMBER: 306001102
VISIT DATE: 01/24/2023
NARRATIVE
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and staff training records. Six of six individuals interviewed could not corroborate the allegation. Four of four individuals interviewed felt they were well-cared for at the facility and denied ever being physically abused by anyone at the facility. The residents appeared clean, well-groomed with no visible injuries observed.

Based on the observations made, interviews which were conducted and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Facility staff physically abused resident while in care is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Manuel Perez and a copy of this report along with the LIC 811 was provided at the time of this visit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2