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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005247
Report Date: 08/29/2024
Date Signed: 08/29/2024 01:02:36 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
08/26/2024 and conducted by Evaluator Edward Kim
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240826143729
FACILITY NAME:FULLERTON PLAZA GUEST HOMESFACILITY NUMBER:
306005247
ADMINISTRATOR:MANGURAY, SEANFACILITY TYPE:
740
ADDRESS:3931 MADONNA DRIVETELEPHONE:
(657) 378-9603
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:6CENSUS: 3DATE:
08/29/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Gerald DiaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not accept resident back after hospital stay.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Edward Kim and Jerome Haley made unannounced visit to investigation a complaint received August 26, 2024. LPAs Kim and Haley were greeted by staff and explained the reason for the visit before entering the facility. The complaint investigation consisted of interviews with facility staff, residents, witnesses, and document review.

Regarding the allegation: Staff did not accept resident back after hospital stay.

3 of 5 individuals interviewed stated the resident decided to move out of the facility. Staff 1 (S1) stated that the resident left on their own. Staff 2 (S2) said, “(the resident) moved out. They took all their clothes and left.” Staff 3 (S3) stated the resident moved out.

Continued on LIC9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
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 2
Control Number 22-AS-20240826143729
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: FULLERTON PLAZA GUEST HOMES
FACILITY NUMBER: 306005247
VISIT DATE: 08/29/2024
NARRATIVE
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Witness interviewed stated the resident is cognizant and is able to make their own choices. Document reviewed revealed that resident is “Mentally he is coherent. He makes his own decisions and has no POA,” and “(Resident) is independent and can do things on his own.”

Based on the information gathered during the investigation through interviews, record reviews, and observation the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed Unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to Administrator Gerald Dia.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2