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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005932
Report Date: 01/08/2024
Date Signed: 01/08/2024 11:56:35 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
12/29/2023 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231229142122
FACILITY NAME:A MOTHER THERESA CAREFACILITY NUMBER:
306005932
ADMINISTRATOR:PAO, WESLEYFACILITY TYPE:
740
ADDRESS:16192 CAIRO CIRCLETELEPHONE:
(714) 792-0967
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 5DATE:
01/08/2024
UNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Maruja Camilon-Caregiver, Wesley Pao-AdministratorTIME COMPLETED:
12:13 PM
ALLEGATION(S):
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Staff did not accept resident back to the facility in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Caregiver Maruja Camilon. LPA explained the reason for the visit. Administrator (AD) Wesley Pao arrived shortly after.

On today’s visit LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: During the investigation LPA reviewed documents including the Unusual Incident/Injury Report (UIIR) dated 12/28/23 for Resident 1 (R1). Per UIIR on 12/26/23 at 9:00 PM Staff 1 (S1) called 911 and around 10:00 PM R1 was transported to Placentia-Linda Hospital. Records reviewed by LPA Ramirez included the Placentia-Linda Hospital Discharge Orders dated 12/28/23 for R1. Per Discharge Orders R1 was admitted to the Hospital on 12/27/23 and was discharged on 12/28/23.
CONTINUED ON LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024
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-20231229142122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: A MOTHER THERESA CARE
FACILITY NUMBER: 306005932
VISIT DATE: 01/08/2024
NARRATIVE
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During interviews conducted with the residents, R1 reported that she was accepted back at the facility in a timely manner and that she was at the Hospital for less than two days. During interviews conducted with staff, Staff 1 (S1) reported that staff never said that they could not take the resident back. During the course of the interviews AD stated that it was a misunderstanding between the facility staff and the Hospital. Per AD R1 returned to the facility as soon as the Hospital was able to find transportation for R1.

Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED.

LPA Ramirez conducted an exit interview with AD Pao , and a copy of this report was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2