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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005633
Report Date: 04/25/2023
Date Signed: 04/25/2023 11:21:16 AM

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
04/20/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230420135153
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: DATE:
04/25/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nestor Librada and Cheryll Amorsolo- Librada, caregiversTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility is not kept clean
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by Nestor and explained the reason for the visit. Administrator Amanda Umali was unavailable.

During the investigation LPA Mendivil obtained copies of resident roster, staff roster and staffing duty schedules. LPA Mendivil interviewed staff and resident, and toured the facility. Regarding the allegation facility is not kept clean, the investigation revealed the following:

LPA Mendivil toured facility, facility is 7 bedrooms, 3 bathroom single story home. LPA Mendivil reviewed staff assignment schedule which outlines staff's cleaning duties daily. Interviews with 3 out of 3 staff indicate they clean daily. Staff reported they clean each resident's room in the morning while the resident is eating breakfast. Interviews with 1 out of 5 residents indicate the facility is very clean. 4 other residents were asleep and unable to be interviewed. CONT on LIC 9099-C dated 04/25/2023.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
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-20230420135153
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: 04/25/2023
NARRATIVE
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While touring the facility LPA observed the bedrooms and bathrooms appear to be clean. LPA did not experience any odors while touring the facility. LPA observed walkways to be clear and free of obstructions. LPA toured outside of facility and did not observe any obstructions to pathways or debris.

Therefore based on the preponderance of evidence through record review, observations made and interviews conducted the allegation that facility is not kept clean is UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint.
No deficiencies cited.

An exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2