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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002429
Report Date: 06/02/2022
Date Signed: 06/02/2022 10:53:35 AM

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
02/04/2022 and conducted by Evaluator Kevin Saborit-Guasch
COMPLAINT CONTROL NUMBER: 22-AS-20220204075525
FACILITY NAME:FAMILY CARE - PEPITA HOMEFACILITY NUMBER:
306002429
ADMINISTRATOR:RUSSELL VENANZIFACILITY TYPE:
740
ADDRESS:26741 PEPITA DRIVETELEPHONE:
(949) 589-0145
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
06/02/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Paul Bartolome, caregiver
Russell Venanzi, Administrator		TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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1) Staff are not properly trained to handle and dispense medications.

3) Staff are not trained to care for resident with restricted health condition.
INVESTIGATION FINDINGS:
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On 06/02/2022, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced to the facility to deliver findings made during the investigation of complaint 22-AS-20220204075525. LPA was greeted and granted entry by Paul Bartolome, caregiver and explained the purpose of the visit. Administrator Russell Venanzi was notified of the visit and arrived later to assist with the visit.
Based on the observations, interviews and file review conducted during the visit on 02/10/2022, LPAs were able to determine that on the allegation that staff trained to handle and dispense medications, LPAs found two staff members for whom training had been completed but not documented.
On the allegation that staff are not trained to care for resident with restricted health condition, LPAs confirmed no training had been documented at the time of the visit and no Home Health Services were involved in the colostomy care. The preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated and are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the report and Appeal Rights were left at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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 4
Control Number 22-AS-20220204075525
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: FAMILY CARE - PEPITA HOME
FACILITY NUMBER: 306002429
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2022
Section Cited
CCR
87411(c)(3)(D)
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87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training (...) (3) The training shall include, but not be limited to, the following:
(...) (D) Policies and procedures regarding medications, (...)
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Licensee agrees to provide documentation of the onboarding and annual training on medication handlign and dispensation.
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This requirement is not met as evidenced by the observations and interviews conducted during the site visit.
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Type A
06/02/2022
Section Cited
HSC
87621
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87621 Colostomy/Ileostomy the licensees shall be responsible for the following: (A) The ostomy bag (...) may be changed by facility staff who have been instructed by the professional. (B) There shall be written documentation by an appropriately skilled professional outlining
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Licensee agrees to provide LPA with documentation of adequate training provided to all facility staff involved in caring for resident R1 colostomy bag.
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 the instruction of the procedures delegated
and the names of facility staff (...)
This requirement is not met as evidenced by the absence
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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: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
02/04/2022 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220204075525

FACILITY NAME:FAMILY CARE - PEPITA HOMEFACILITY NUMBER:
306002429
ADMINISTRATOR:RUSSELL VENANZIFACILITY TYPE:
740
ADDRESS:26741 PEPITA DRIVETELEPHONE:
(949) 589-0145
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
06/02/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Paul Bartolome, caregiver
Russell Venanzi, Administrator		TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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9
2) Provider did not have staff files/ records or clearances for staff observed.

5) Staff is claiming to be LVN but is not licensed by Vocation Board of Nursing for California.
INVESTIGATION FINDINGS:
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On 06/02/2022, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced to the facility to deliver findings made during the investigation of complaint 22-AS-20220204075525. LPA was greeted and granted entry by Paul Bartolome, caregiver and explained the purpose of the visit. Administrator Russel Venanzi was notified of the visit and arrived later to assist with the visit.
Based on the observations, interviews and file review conducted during the visit on 02/10/2022, LPA was able to make the following determinations. On the allegation that provider did not have staff files/ records or clearances for staff observed, LPA verified all staff present to be properly associated and cleared. On the allegation that staff is claiming to be an LVN but is not licensed, LPA confirmed staff in question is not employed as a nurse and does not provide nursing care.
Although the allegation may have happened or iarevalid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, report was reviewed and copy of this report was provided during the visit to facility representative.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4