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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006091
Report Date: 02/17/2023
Date Signed: 02/17/2023 11:32:59 AM

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
05/31/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220531115206
FACILITY NAME:PRISTINE HOME CAREFACILITY NUMBER:
306006091
ADMINISTRATOR:ALVARADO, MARY JEANFACILITY TYPE:
740
ADDRESS:9252 PACIFIC AVETELEPHONE:
(714) 749-7237
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 6DATE:
02/17/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jakelin MijaresTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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9
Staff speaks inappropriately towards a resident while in care
Staff inappropriately pushed a resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by Caregiver Jakelin Mijares and explained the reason for the visit. Administrator Mareties Pontoy arrived during the visit.

During the course of the investigation, LPA toured the facility and interviewed staff and witnesses. Regarding the allegations that staff speaks inappropriately towards a resident while in care and staff inappropriately pushed a resident while in care, the investigation revealed the following: Per witnesses interviewed, there is a recording of inappropriate verbiage by Staff 1 (S1) directed towards Resident 1 (R1). Witness is unwilling to provide a copy of the recording to the department and S1 declined to speak with LPA. S1 is currently not associated to any other facilities licensed by Community Care Licensing. LPA was unable to interview R1 due to cognitive decline. Two out of two residents and two out of two staff interviewed at the facility deny any knowledge of verbal or physical abuse by S1 or any caregiver. Therefore, the allegation is deemed unsubstantiated, CONTINUED ON LIC 9099C DATED 02/17/2023
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
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-20220531115206
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: PRISTINE HOME CARE
FACILITY NUMBER: 306006091
VISIT DATE: 02/17/2023
NARRATIVE
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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. An exit interview was conducted with and a copy of this report was provided to facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2