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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005780
Report Date: 10/24/2022
Date Signed: 10/24/2022 02:54:55 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
10/19/2022 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221019153708
FACILITY NAME:CANDLEBERRY CAREFACILITY NUMBER:
306005780
ADMINISTRATOR:ROSARIO, ROBERTO DELFACILITY TYPE:
740
ADDRESS:4216 CANDLEBERRY AVE.TELEPHONE:
(949) 290-6006
CITY:SEAL BEACHSTATE: CAZIP CODE:
90740
CAPACITY:6CENSUS: 3DATE:
10/24/2022
UNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH:Udarico "Rico" AlmiranezTIME COMPLETED:
02:59 PM
ALLEGATION(S):
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Facility doesn't have Let Us Know Poster posted in the facility.
INVESTIGATION FINDINGS:
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 On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz made an unannounced visit to the facility to conduct a 10 day visit to address the allegation listed above. LPA Quiroz was COVID-19 screened and granted entry by Caregiver 1. LPA Quiroz met with (L/AD) Almiranez and discussed the purpose for today’s visit.
During today's visit, LPA Quiroz along with (L/AD) Almiranez conducted a facility tour inspection of interior and exterior of facility premises. During the course of this investigation, LPA Quiroz conducted multiple interviews with interviewees and conducted facility premises observations on today's date.
Based on the preponderance of evidence gathered through multiple interviews and observations, the allegation “Facility doesn't have Let Us Know Poster posted in the facility” has been met; Therefore, the allegation listed above is deemed to be SUBSTANTIATED.
The facility is being cited per Title 22, Division 6 of the California Code of Regulations. (SEE LIC 9099-D)
An exit interview was conducted with (L/AD) Almiranez, and a copy of this report, along with LIC9099-D, Appeal Rights, and the LIC 811-Confidential names were provided at exit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
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-20221019153708
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: CANDLEBERRY CARE
FACILITY NUMBER: 306005780
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2022
Section Cited
CCR
87468(A)
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87468(A): Personal Rights:Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster...The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility... This requirement was not met CONTINUED...
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L/AD Almiranez will make copy of poster in 20'' x 26'' measurements and post it in the main entryway of the facility and submit proof to CCL by 10/26/2022.
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CONT...as evidenced by: Based on today's facility inspection visit and observations made during today's visit, LPA Quiroz did not observe Let Us Know Poster posted in the main entryway of the facility. This poses a potential 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC9099 (FAS) - (06/04)
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