306005478-1-11-2024-22-AS-AORZ-CZQT93-20240122133117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005478
Report Date: 01/11/2024
Date Signed: 01/11/2024 02:19:47 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
10/05/2020 and conducted by Evaluator Jenifer Tirre

COMPLAINT CONTROL NUMBER: 22-AS-20201005102352

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:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Caregiver Kristine Guevarra		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff left residents unsupervised in the facility.
Staff did not properly store medications.
Staff did not manage residents’ medication properly.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection to deliver findings on a complaint investigation. LPA identified themselves and discussed the purpose of the visit and the elements of the allegations with Caregiver.

During course of the investigation, the department interviewed staff, residents, and witnesses as well as reviewed documentation. The investigation conducted revealed the following:
On 10/5/2020, it was reported that Staff left residents unsupervised in the facility, staff did not properly store medications and staff did not manage residents medications properly.

Based on interviews conducted with staff, four of four staff members stated that facility residents were not left alone in the facility. Four of four staff confirmed that staff member S1 was at facility inside staff room during the time of alleged non-supervision on 10/2/2020. CONTINUED ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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-20201005102352

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: SAINT BENEDICT CARE LLC	FACILITY NUMBER: 306005478
	VISIT DATE: 01/11/2024

NARRATIVE

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Interviews revealed that S1 did not hear resident call out for help and therefore did not respond to resident in timely manner. Four of four staff confirm that they have never left residents unsupervised alone at the facility and staff confirmed their awareness that leaving residents alone is considered neglect. Based on interviews with residents, three of three residents interviewed stated staff have never left residents unattended at the facility. Interviews with residents confirmed that three of three residents stated they like the level of care being provided at facility. Fountain Valley Police Department Report confirms Police Department was contacted and came out to facility to do a Wellness Check on 10/02/20. Police Document did not state any concerns of abuse or neglect reported at facility.

Based on interviews conducted with staff, all staff interviewed confirm that medications are stored inside secure medication closet with staff responsible for holding onto closet key. Based off interviews conducted with residents, three of three residents confirm they receive medications at scheduled times. LPA’s observations confirmed medications are centrally stored inside a secure medication closet. Facility documents revealed that staff have completed training in Psychosocial needs of the elderly, Medication Administration, and Understanding abuse & neglect.

Based off interviews, observations and records reviewed, LPA is unable to corroborate allegations made that the facility staff left residents unsupervised in the facility, Staff did not properly store medications and Staff did not manage resident’s medications properly therefore although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are deemed UNSUBSTANTIATED.

An exit interview was conducted with staff and a copy of this report along with a LIC 811 Confidential Names list was provided during this visit.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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