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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005633
Report Date: 07/08/2022
Date Signed: 07/08/2022 01:50:31 PM

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
03/29/2022 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220329090741
FACILITY NAME:MARYKNOLL SENIOR CAREFACILITY NUMBER:
306005633
ADMINISTRATOR:UMALI, FRANCES AMANDAFACILITY TYPE:
740
ADDRESS:531 WHITTEN WAYTELEPHONE:
(805) 836-1556
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 6DATE:
07/08/2022
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Cheryll AmorsoloTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Unclear adult living at facility
Facility staff do not safeguard resident's confidential records
Facility staff do not ensure a safe and healthful environment for residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michelle Reed met with Staff Cheryll Amorsolo to discuss the complaint findings for the above allegations.Administrator Amanda Umali was contacted via telephone. She was in a meeting and could not come to the facility. The investigation consisted of interviews with staff, Administrator, and witnesses as well as documentation from the facility. The following was determined:

The Department received a complaint regarding allegations that an unclear adult was living at the facility and that staff do not safeguard resident records or provide a safe and healthful environment for residents.

Resident #1(R1) moved into the facility on or around 3/15/22. According to Administrator Amanda Umali, R1 lived on his own, but after his most recent hospitalization required more assistance. Since R1’s relative also lived in the facility, Ms. Umali allowed R1 to move in. R1 was not listed as a resident of the facility and there was no admission agreement or Physician’s report for R1. LPA was provided with a Preadmission Appraisal, Identification and Emergency Information, and a Plan of Care. The forms were dated on 3/29/22 with an admission date of 3/29/22. LPA also reviewed associations for the facility and did not see that R1 was fingerprint cleared prior to becoming a resident.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
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 4
Control Number 22-AS-20220329090741
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: MARYKNOLL SENIOR CARE
FACILITY NUMBER: 306005633
VISIT DATE: 07/08/2022
NARRATIVE
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On 4/3/22, a tour of the physical plant was conducted at the facility and records were reviewed. At the time of visit, resident records were stored in an unlocked closet. This did not ensure confidentiality.

Interviews regarding an unsafe and unhealthful environment disclosed that R1 was observed in the hallway in his underwear or a towel and was often heard yelling at R2,

Based upon the review of records and interviews, the preponderance of evidence has been met and the allegations are substantiated.

See LIC9099D for cited deficiencies.

An exit interview was conducted and a copy of this report and appeal rights were provided to Cheryll Amorsolo.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20220329090741
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: MARYKNOLL SENIOR CARE
FACILITY NUMBER: 306005633
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2022
Section Cited
CCR
87355(e)(1)(2)
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87355(e)(1)(2) Criminal Record Clearance-All individuals subject to a criminal record review shall obtain a California clearance or a criminal record exemption as required by the Department or request a transfer of a criminal record clearance as specified in Section 87355 prior to working, residing or volunteering in a licensed facility.

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Licensee/Administrator agrees to fingerprint all staff and non-residents before working or residing in the facility. Proof of understanding will be provided by 7/7/22.

Civil penalties assessed

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This requirement was not met as evidenced by:

R1 was living in the home on or around 3/15/22 and was not fingerprint cleared prior to becoming a resident on 3/29/22. This poses an immediate health and safety risk to residents in care.
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Type B
07/11/2022
Section Cited
CCR
87506(c)
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Resident Records- All information and records obtained from or regarding residents shall be confidential.

This requirement was not met as evidenced by:

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Licensee/Administrator agrees to store resident records in a locked closet, cupboard or office to ensure confidentiality. Proof of confidential storage will be provided by 7/7/22

Records were locked on today's date 7/8/22..


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On 4/3/22, at the time of visit, resident records were observed in an unlocked closet. This did not ensure confidentiality. This poses a potential personal rights risk to residents 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: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 22-AS-20220329090741
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: MARYKNOLL SENIOR CARE
FACILITY NUMBER: 306005633
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/11/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights- Residents in all residential care facilities for the elderly shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:

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Licensee agrees to protect all resident rights to ensure a safe and healthful environment. Proof of understanding of this subsection will be provided by 7/7/22


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Interviews with staff and residents disclosed that R1 was observed in the hallway in his underwear or a towel. R1 was also heard yelling at R2. This poses a personal rights risk to residents 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: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4