306005478-3-14-2023-22-AS-AORZ-CQ4NG8-20230320102640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005478
Report Date: 02/01/2023
Date Signed: 03/14/2023 01:13:57 PM

Unfounded

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
11/14/2022 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221114115222

FACILITY NAME:	SAINT BENEDICT CARE LLC		FACILITY NUMBER:	306005478
ADMINISTRATOR:	ALMIRANEZ, ULDARICO		FACILITY TYPE:	740
ADDRESS:	8925 CANARY AVENUE		TELEPHONE:	(949) 290-6006
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	11:22 AM
MET WITH:	Kristine Guevarra, Lead Caregiver and Uldarico "Rico" Almiranez, Licensee/Administrator		TIME COMPLETED:	03:12 PM

ALLEGATION(S):

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-Staff not responding to resident's emergency calls.
-Staff forged resident's signature on a document.

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose of concluding and delivering findings to address the allegations listed above. The 10 day visit complaint investigation was conducted on 11/21/2022. On today's date, LPA Quiroz arrived to the facility and was greeted, COVID-19 screened and met with Licensee/Administrator Uldarico Almiranez LPA Quiroz discussed purpose of today's visit.
During the course of the investigation the following was reviewed for six of six residents residing at the facility: Physician reports, identification forms and needs and services plans.
Regarding the allegation “Staff are not responding to resident’s emergency calls,” LPA Quiroz conducted multiple interviews with interviewees consisting of residents, staff and other witnesses. Interviews conducted with nine of ten Interviewees revealed that staff are responding to resident’s emergency calls indicating staff are available to assist resident’s requests and needs. CONTINUED...
***THIS IS AN AMENDED REPORT***

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221114115222

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: SAINT BENEDICT CARE LLC	FACILITY NUMBER: 306005478
	VISIT DATE: 02/01/2023

NARRATIVE

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CONTINUED...

Based on the evidence gathered from interviews conducted with ten interviewees, LPA Quiroz’s observations during inspection visits of 11/21/22 and 2/1/23, and a review of pertinent documentation, the allegation: "staff are not responding to resident’s emergency calls” is deemed Unfounded, meaning that the allegation was false, could not have happened or is without a reasonable basis; Therefore complaint allegation is dismissed.
Regarding the allegation “Staff forged resident’s signature on a document,” 4 residents interviewees reported that staff are not forging their signatures on documents. Nine of ten interviewees did not corroborate with the allegation "Staff forged resident’s signature on a document." During the course of the investigation, LPA Quiroz reviewed video evidence. During video evidence review, LPA Quiroz was able to listen to conversation between Resident 1 (R1) and (L/AD) Almiranez where (L/AD) Almiranez is heard requesting for R1 to sign the admission agreement; (R1) can be heard indicating that he was requested to sign the admission agreement and not signing his finances over to the facility. However, the document being signed is not visible as video recording reflects recording of a wall, R1's face and pictures displayed on the wall. Interview conducted with R1 on 9/7/2022 regarding Complaint control # 22-AS-20220829124546 revealed confirmation that R1 signed the admission agreement and hand-written document indicating R1 is handing over disability benefits to facility effective 10/2021.
Based on the evidence gathered from interviews conducted with ten interviewees, video evidence and a review of pertinent documentation, the allegations: "Staff forged resident’s signature on a document” is deemed Unfounded, meaning that the allegation was false, could not have happened or is without a reasonable basis; Therefore complaint allegations is dismissed.

An exit interview was conducted with Licensee/Administrator Uldarico Almiranez, and a copy of this report along with LIC 811- Confidential Names list were provided to Facility at exit.

***THIS IS AN AMENDED REPORT***

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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