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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001960
Report Date: 10/30/2024
Date Signed: 10/30/2024 02:44:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
10/21/2024 and conducted by Evaluator Dwayne L Mason
COMPLAINT CONTROL NUMBER: 22-AS-20241021103457
FACILITY NAME:ECLC - WAKE FOREST VILLAFACILITY NUMBER:
306001960
ADMINISTRATOR:ANGELITA DAVIDFACILITY TYPE:
740
ADDRESS:233 WAKE FOREST RD.TELEPHONE:
(714) 434-9489
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 5DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Angelita David - AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility is withholding resident's mail.
INVESTIGATION FINDINGS:
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This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to initiate and conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by facility staff. LPA met with Angelita David, Administrator and explained the nature of the inspection.

The department received a complaint on 10/21/2024 stating Facility is withholding resident's mail. During the investigation, the department interviewed the Administrator (AD), staff and residents in care.

On 10/30/2024 LPA conducted a visit to the facility. LPA obtained copies of personnel reports, resident roster, photos of resident's physician's report, admission agreement,resident mail and photos of text messages.

(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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 22-AS-20241021103457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ECLC - WAKE FOREST VILLA
FACILITY NUMBER: 306001960
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2024
Section Cited
CCR
87468.1(a)(15)
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(15) To send and receive unopened correspondence in a prompt manner.

This licensee did not comply with the section cited above due to R1's mail being observed in the AD's bedroom after R1 requested all their mail be given to them on 8/23/24.
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LPA observed facility staff return all of R1's mail during the visit on 10/30/2024. LPA observed no resident mail in facility staff room on 11/19/2024. LPA cleared the deficiency during the visit.
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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: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20241021103457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ECLC - WAKE FOREST VILLA
FACILITY NUMBER: 306001960
VISIT DATE: 10/30/2024
NARRATIVE
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(continued from LIC9099)

LPA conducted interviews with Residents (R2, R3 and R4). Based on these interviews, LPA was unable to determine if the facility is withholding other R2, R3 or R4's mail. LPA conducted interviews with R1 and AD. R1 and AD both stated R1 is able to manage their own mail. R1 and AD both confirmed that R1 sent AD a text message on August 23, 2024 stating "as of this date I would like all my mail given to me". During the facility tour, LPA observed a box of documents in the Administrator's bedroom. LPA observed unopened checks, medical reports, invoices and other documents addressed to R1 in the box in the Administrator's room.

Based on record review, LPA determined the facility is not R1's conservator or responsible party and R1 does not have any diagnoses that would indicate they are unable to manage their own mail. R1's most recent physician's report indicates that R1 is able to manage their own cash resources as well.

Per Title 22 Regulation 87468.2(a)(1) "To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups."

Based on interviews conducted, records reviewed and observations made, the facility did not comply with the regulation stated above due to the observation of R1's mail in the AD's room after R1 had requested AD give them all of their mail.

The preponderance of evidence standard has been met. The allegation is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3