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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006034
Report Date: 09/24/2024
Date Signed: 09/24/2024 11:36:52 AM

Substantiated


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
09/18/2024 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240918082726
FACILITY NAME:PHAMILY HOME ELDERLY CARE 2FACILITY NUMBER:
306006034
ADMINISTRATOR:PHAM, CHARLESFACILITY TYPE:
740
ADDRESS:16652 HUGGINS AVETELEPHONE:
(657) 724-9930
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 5DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Lolita Orcullo-Caregiver, Charles Pham-AdministratorTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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Staff abandoned resident at hospital.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Samer Haddadin conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPAs were greeted and granted entry into the facility and met with Caregiver Lolita Orcullo. LPAs explained the reason for the visit. Administrator (AD) Charles Pham arrived shortly after.

This agency has investigated the complaint alleging that staff abandoned resident at hospital. Regarding the allegation, the following was revealed: Three of five individuals interviewed confirmed the allegation. During the course of the interviews with witnesses, Witness 1 (W1) reported that Resident 1 (R1) was abandoned at the Hospital. Per W1 R1 is currently at Placentia Linda Hospital and stated that they are having issues finding R1 a home. W1 stated that the AD told the Hospital that he did not want R1 back at the facility. During the course of the interviews with staff, Staff 1 (S1) reported that R1 was not issued an Eviction notice. Per S1 R1 is not coming back to the facility.
CONTINUED ON LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
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 4
Control Number 22-AS-20240918082726
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: PHAMILY HOME ELDERLY CARE 2
FACILITY NUMBER: 306006034
VISIT DATE: 09/24/2024
NARRATIVE
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Per AD he is not able to accept R1 back into the facility due to many complaints about his inappropriate behaviors toward staff. AD reported that R1 did not received an Eviction notice and stated that he told the Hospital to find a new place for R1.

Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff abandoned resident at hospital is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with facility representative and a copy of this report along with the Appeal Rights were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20240918082726
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: PHAMILY HOME ELDERLY CARE 2
FACILITY NUMBER: 306006034
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2024
Section Cited
CCR
87224(a)(3)(4)
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87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...(3)Failure of the resident to comply with general policies of the facility. (4) If, after
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Licensee to issue a 30-Day Eviction notice to R1 and email a copy to LPA by POC due date.
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admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463... Based on record review and interviews conducted R1 was not issued a 30-Day Eviction notice. This poses a potential health, safety or personal rights risk to persons 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: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20240918082726
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: PHAMILY HOME ELDERLY CARE 2
FACILITY NUMBER: 306006034
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
87464(f)(1)
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(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidence by: Based on interviews conducted AD reported
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Licensee to read and sign a statement of understanding. Licensee to email a copy to LPA by POC due date.
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he is not able to take R1 back into the facility. Per AD he told the Hospital to find a new place for R1. This poses an immediate health, safety or personal rights risk to persons 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: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4