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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005273
Report Date: 03/30/2023
Date Signed: 03/30/2023 02:25:17 PM

Unsubstantiated


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
03/23/2023 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230323145321
FACILITY NAME:NORA'S RESIDENCE OF PLACENTIAFACILITY NUMBER:
306005273
ADMINISTRATOR:DIMAANO, EUPHROSYNEFACILITY TYPE:
740
ADDRESS:1217 WARREN STREETTELEPHONE:
(714) 310-9495
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 5DATE:
03/30/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Euphrosyne DimaanoTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility retained residents with a prohibited health condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made unannouced visit to intiatate the investigation into the complaint received against this facility on March 23, 2023. LPA Haley was greated by staff and explained the reason for the visit.

LPA Haley discussed the complaint allegation and interviewed Administraotr (AD) Euphrosyne Dimaano, Staff 1 (S1), and Staff 2 (S2) to gather information on the complaint allegation above.

Regarding the allegation, Facility retained residents with a prohibited health condition.

During the complaint visit, LPA Haley was provided documentation for Resident 1 (R1), Resident 2 (R2), and Resident 3 (3) that allows the residents to be retained in the facility without a written exemption request for a prohibited health condition.
Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
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-20230323145321
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: NORA'S RESIDENCE OF PLACENTIA
FACILITY NUMBER: 306005273
VISIT DATE: 03/30/2023
NARRATIVE
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According to California Code of Regulations (CCR) Section 87616(c) Exceptions For Health Conditions,
"Facilities that have satisfied the requirements of Section 87632, Hospice Care Waiver, are not required to submit written exception requests under this section for residents or prospective residents with restricted health conditions under Section 87612 and/or prohibited health conditions under Section 87615 provided those residents have been diagnosed as terminally ill and are receiving hospice services in accordance with a hospice care plan as required under Section 87633, Hospice Care for Terminally Ill Residents, and the treatment of such restricted and/or prohibited health conditions is specifically addressed in the hospice care plan."

Based on the information gathered during the investigation, review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2