306005829-3-28-2024-22-AS-AORZ-D4TS2X-20240430133016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005829
Report Date: 03/28/2024
Date Signed: 03/28/2024 04:23:47 PM

Unsubstantiated

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
03/07/2022 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220307154845

FACILITY NAME:	MT. SHERROD HOME, LLC.		FACILITY NUMBER:	306005829
ADMINISTRATOR:	VIVIAN LUIS-ORTIZ		FACILITY TYPE:	740
ADDRESS:	16550 MT. SHERROD CIRCLE		TELEPHONE:	(714) 839-4417
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	6	CENSUS: 6	DATE:	03/28/2024
		UNANNOUNCED	TIME BEGAN:	02:32 PM
MET WITH:	Geraldine Doan, Administrator		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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-Staff were under the influence of drugs.
-Resident was illegally evicted.

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose to conduct additional interviews and deliver findings regarding allegations listed above. LPA Quiroz was greeted by Caregiver 1 (CG1). Licensee (L) Thi Doan and Administrator (AD) Geraldine Doan arrived shortly after and discussed purpose of today's visit. The 10-day inspection visit was conducted by LPA Quiroz on 3/15/2022 and complaint follow up inspection visits were conducted on December 8, 2023 and March 28, 2024.
During the course of the investigation, LPA Quiroz conducted interviews with interviewees consisting of staff and residents. LPA Quiroz conducted documentation review of resident roster, staff roster, physician reports, identification forms and Client/Resident Personal Property and Valuables for Resident 1 (R1) and Resident 2 (R2).
Regarding the allegation "Staff were under the influence,” the investigation revealed the following, LPA Quiroz interviewed staff and residents. Six of six staff and three of six residents denied the allegation indicating no knowledge of staff being under the influence of drugs in the facility. CONTINUED...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2023

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-20220307154845

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: MT. SHERROD HOME, LLC.	FACILITY NUMBER: 306005829
	VISIT DATE: 03/28/2024

NARRATIVE

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LPA Quiroz conducted facility inspection visits on: March 15,2022, December 8,82023 and March 28, 2024 and did not observe staff to be under the influence of drugs and alcohol.
On February 7, 2022, the Responsible Party of R1 and R2 packed their belongings. The LIC 621 Clients/Residents Personal Property and Valuables showed all items packed and taken at the time of discharge. Former Administrator went over the items with the responsible party who signed the document acknowledging items received. At that time no drug paraphernalia was observed to be present with the belongings.
Regarding the allegation "Resident was illegally evicted," the investigation revealed the following: Interviews conducted with (L) Thi Doan and (AD) Geraldine Doan and documentation review of Client/Resident Personal Property and Valuables for (R1) and (R2) concluded (R1) and (R2) were discharged from the facility on February 7, 2022 per responsible party’s decision. (AD) Doan indicated (R1) was transferred to hospital on January 4, 2022 and transferred to skilled nursing facility on Decmebr 12,2022 due to higher level of care needs. (AD) Doan indicated (R1s) responsible party was reimbursed for (R1s) room share with a total of $2308.08. Although a 30-day notice was verbally given by responsible party, there was no written follow up by either Facility Representative or Responsible Party. However, a refund was still issued to responsible party. (AD) Doan indicated (R2) was transferred to Emergency room on January 31, 2022 and then transferred to skilled nursing facility due to higher level of care needs. (AD) Doan received a check in the amount of $2,650 on January 29, 2022 for (R2s) room share cost . (R2) left to the hospital on January 31,2022 and never returned. (AD) Doan did not cash the check and returned the check on January 31, 2022. (AD) Doan called (R2s) responsible party who stated (R2) would not be returning to the facility and would remain at Skilled nursing facility. Documentation review of Client/Resident Personal Property and Valuables for (R1) and (R2) note signature signed by responsible party on date February 7, 2022.
Therefore based on the preponderance of evidence gathered through interviews, observations conducted by LPA Quiroz and documentation review, the allegations that the "Staff were under the influence of drugs” and “Resident was illegally evicted” are deemed UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.
This agency has investigated this complaint. No deficiencies cited during today's visit.

An exit interview was conducted with (L) Thi Doan and (AD) Geraldine Doan and a copy of report and LIC 811-Confidential Names were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC9099 (FAS) - (06/04)

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