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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001749
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:12:41 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
10/04/2022 and conducted by Evaluator Claudia Gutierrez
COMPLAINT CONTROL NUMBER: 22-AS-20221004201130
FACILITY NAME:ARVILINH HOME CAREFACILITY NUMBER:
306001749
ADMINISTRATOR:ARVIN BUMANGLAGFACILITY TYPE:
740
ADDRESS:9351 MELBA DRIVETELEPHONE:
(714) 643-9077
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 5DATE:
10/11/2022
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Nilo Garcia
Arvin Bumanglag
Linh Nguyen		TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility failed to accord Resident with privacy.

Facility failed to obtain approval to install cameras in residents' rooms.
INVESTIGATION FINDINGS:
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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Administrator (AD) Arvin Bumanglag and Registered Nurse (RN) Linh Nguyen. LPA was taken on a guided tour of the of the facility by Staff 1 (S1) Nilo Garcia.

Complaint alleges facility failed to accord Resident with privacy and facility failed to obtain approval to install cameras in residents' rooms.

Interviews was conducted with AD, S1, and Resident 1 (R1). All parties interviewed confirmed there are surveillance cameras in resident rooms. LPA observed and obtained a picture of cameras in four out of five resident rooms. AD stated that a waiver for the cameras had not yet been submitted to the Department and that their spouse was "working on it." (Cont. LIC 9099-C)


Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
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-20221004201130
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: ARVILINH HOME CARE
FACILITY NUMBER: 306001749
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2022
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights
(a) residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations

This requirement is not met as evidence by;
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Administrator (AD) immediately removed cameras. AD stated cameras would no longer be used until a waiver is submitted to the Department and approved. LPA observed the cameras were no longer in five out of five resident rooms.
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LPA observed and obtained a picture of cameras in four out of five resident rooms.
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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: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20221004201130
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: ARVILINH HOME CARE
FACILITY NUMBER: 306001749
VISIT DATE: 10/11/2022
NARRATIVE
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Per disclosures made during interviews, and observations made by LPA, it was determined that facility failed to accord residents with privacy and facility failed to obtain approval to install cameras in residents' rooms. Based on LPA’s observation of cameras in four out of five resident bedrooms and all parties interviewed collectively confirming surveillance cameras were placed in resident rooms by AD, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated California Code of Regulations, Title 22, 87468.2(a)(1),

An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3