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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005754
Report Date: 05/18/2023
Date Signed: 08/02/2023 10:30:55 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
05/09/2023 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230509135044
FACILITY NAME:MILES PLACE OF FOUNTAIN VALLEYFACILITY NUMBER:
306005754
ADMINISTRATOR:AVENDANO, REINERFACILITY TYPE:
740
ADDRESS:18667 SAN FELIPE STREETTELEPHONE:
(949) 273-9951
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
05/18/2023
UNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Mark Cruz, Administrator and Analyn Tangonan, Caregiver and Jenlyn Dionisio, Office ManagerTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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-Staff did not ensure resident's mattress was clean
-Staff did not ensure residents room was clean
-Staff did not ensure resident had toilet paper
-Resident's appearance is unkempt due to staff neglect
-Staff did not ensure resident's bathroom was clean
INVESTIGATION FINDINGS:
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz made an unannounced visit to conduct a 10 day inspection visit to address the allegations listed above. LPA Quiroz was greeted by Caregiver Analyn Tangonan. LPA Quiroz called and spoke to Administrator (AD) Mark Cruz from facility telephone and discussed purpose of today's visit. (AD) Mark Cruz arrived to the facility shortly after.
Regarding the allegations "Staff did not ensure resident's mattress was clean," "Staff did not ensure residents room was clean," "Staff did not ensure resident had toilet paper," "Resident's appearance is unkempt due to staff neglect," and "Staff did not ensure resident's bathroom was clean." The investigation revealed the following:
Documentation review of previous Annual inspection visit conducted on 5/5/2022 revealed that there were 6 residents residing at this facility. During today's visit, LPA Quiroz observed the same residents residing at this facility as during the Annual inspection visit conducted on 5/5/2022, of which none of the 6 of 6 residents observed during today's visit were identified as (R1).
CONTINUED...***THIS IS AN AMENDED REPORT***
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
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-20230509135044
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: MILES PLACE OF FOUNTAIN VALLEY
FACILITY NUMBER: 306005754
VISIT DATE: 05/18/2023
NARRATIVE
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CONTINUED...Interviews conducted with three of three staff denied ever having a resident by the name of Resident 1 (R1). Administrator Mark Cruz indicated overseeing twelve facilities indicating "I know my residents very well, current and past and have never had a resident by the name of (R1)."

Therefore based on the preponderance of evidence through interviews, documentation review and observations conducted by LPA Quiroz, the allegations that the "Staff did not ensure resident's mattress was clean," "Staff did not ensure residents room was clean," "Staff did not ensure resident had toilet paper," "Resident's appearance is unkempt due to staff neglect," and "Staff did not ensure resident's bathroom was clean" are UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. This agency has investigated this complaint.

No deficiencies cited during today's visit.

An exit interview was conducted with (AD) Mark Cruz, and a copy of report was provided.

***THIS IS AN AMENDED REPORT***
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2