306005856-5-24-2023-22-AS-SSAS-CS62U8-20230524174154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005856
Report Date: 05/24/2023
Date Signed: 05/24/2023 12:53:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 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
05/10/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230510144030

FACILITY NAME:	HAVEN FOR MOM & DAD 1		FACILITY NUMBER:	306005856
ADMINISTRATOR:	CALMA, RHODA		FACILITY TYPE:	740
ADDRESS:	1221 SIERRA VISTA DR		TELEPHONE:	(562) 228-4439
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	6	CENSUS: 6	DATE:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rhoda Calma, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility is violating resident’s personal rights

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA was greeted and granted entry by caregiving staff after explaining the purpose of the visit. Administrator Rhoda Calma was notified via telephone and arrived shortly afterwards to assist with the visit.

The initial complaint investigation visit was conducted on May 16, 2023. LPA accompanied by administrator conducted a tour of the physical plant, reviewed resident files for three of the current residents and attempted or conducted interviews with all six resident present at the time of the visit. LPA additionally conducted an interview with facility administrator along with an interview with one caregiving staff member.

Additional phone interviews conducted on May 24, 2023
CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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-20230510144030

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HAVEN FOR MOM & DAD 1	FACILITY NUMBER: 306005856
	VISIT DATE: 05/24/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099

Regarding the allegation that Facility is violating resident’s personal rights, the following has been concluded: The resident's right to receive visitors is being respected as confirmed by a review of the facility's visitation log for a period from October 23, 2022 until May 16, 2023 showing a diversity of visitors allowed into the facility at times generally within recommended visitation hours but also later than 6pm on occasion. The resident's health condition was corroborated by observation, records reviewed including notes from hospice staff and interviews conducted and appears fully consistent with accounts made of the necessity to respect the resident's sleep schedule and increased need for uninterrupted rest as evidenced by the resident's primary care physician as well as hospice staff.

It was additionally confirmed that during a visit conducted after the recommended visitation hours that occurred on May 5, 2023, one of the facility staff member proceeded to monitor and film the visit in order to confirm orders regarding the resident's rest were being followed. When the visitors requested privacy, staff member complied and later apologized to the visitors. Additionally, the facility has obtained the permission to photograph the resident (outside of promotional purposes) upon signature of the admission agreement on March 28, 2021.

Based on the investigation conducted, no violation of the resident's personal rights could be evidenced. The allegation is therefore deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No citations issued during today's visit.

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

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

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