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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003406
Report Date: 11/22/2022
Date Signed: 11/22/2022 11:29:18 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
11/17/2022 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221117092305
FACILITY NAME:ORANGE MANOR, THEFACILITY NUMBER:
306003406
ADMINISTRATOR:AIDA MARTIRESFACILITY TYPE:
740
ADDRESS:1824 NORTH SHAFFER ST.TELEPHONE:
(714) 283-2474
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:6CENSUS: 6DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:Facility Administrator-Aida MartiresTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Facility staff are not properly trained.
Facility staff are not background checked and associated to facility.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Celine De Perio and Joseph Alejandre made an unannounced 10-day visit to this facility to conduct an investigation for the complaint received on 11/17/2022 and to deliver the findings for the allegations indicated above. LPAs De Perio and Alejandre arrived to facility at 8:03 AM, and explained reason for visit and was greeted and granted entry by facility administrator (AD) Aida Martires. Upon arrival, LPAs De Perio and Alejandre conducted a tour of the interior portion of the facility with AD Martires.

For today's visit, there are a total of 6 residents in care of which 3 are on hospice and 2 staff members on duty.

On today’s visit, LPAs De Perio and Alejandre conducted file reviews, obtained pertinent documents, and conducted interviews.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
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-20221117092305
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: ORANGE MANOR, THE
FACILITY NUMBER: 306003406
VISIT DATE: 11/22/2022
NARRATIVE
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This agency has investigated the allegation that facility staff are not properly trained. LPAs De Perio and Alejandre reviewed 4 staff files, of which only 1 included the required staff training, while the remaining 3 files for 3 staff members did not have the required 20-hours of annual staff training. Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

This agency has investigation the allegation that facility staff are not background checked and associated to facility. Based on LPAs observations and interviews which were conducted and record review, one out of the two staff present at facility for this visit did not complete a background check, nor receive clearance. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Civil penalty assessed and issued.

For today's visit a civil penalty and citations were issued per Title 22 Division 6 of the California Code of Regulations. See LIC9099-D and LIC421BG.

LPAs De Perio and Alejandre also provided AD Martires information regarding the Guardian system.

LPAs De Perio and Alejandre conducted an exit interview with AD Martires and a copy of this report, citations, civil penalty, and Appeal Rights were provided to the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20221117092305
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: ORANGE MANOR, THE
FACILITY NUMBER: 306003406
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2022
Section Cited
HSC
1569.625(b)(2)
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1569.625(b)(2) Staff training; legislative findings; contents
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...

This requirement is not met as evidenced by:
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As plan of correction (POC), administrator will submit proof of completed required staff trainings to CCL and assigned LPA on or by 11/23/22.
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Based on observation, record reviews and interviews, facility did not ensure that 3 out of the 4 staff files reviewed, had the required 20-hours of annual training, which poses an immediate health and safety or personal rights risk to persons in care.
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Type A
11/22/2022
Section Cited
CCR
87335(b)
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87355 Criminal Record Clearance
(b)...any adults other than a client, residing in the facility shall have criminal record clearance or exemption.

This requirement is not met as evidenced by:
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As plan of correction (POC) administrator will ensure that all staff members and volunteers in the facility will receive clearance prior to working in the facility, and will submit proof to CCL and assigned LPA on or by 11/23/22.
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Based on observation, record reviews, and interviews, facility did not comply with the section cited above as LPAs observed no clearance for one of the staff present at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
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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: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3