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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006153
Report Date: 05/01/2025
Date Signed: 05/01/2025 05:19:32 PM

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
04/22/2025 and conducted by Evaluator Edward Kim
COMPLAINT CONTROL NUMBER: 22-AS-20250422094955
FACILITY NAME:CARE JANELLAFACILITY NUMBER:
306006153
ADMINISTRATOR:JULIE G CORNEJOFACILITY TYPE:
740
ADDRESS:17072 SAGA DRIVETELEPHONE:
(714) 683-4617
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 3DATE:
05/01/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Caregiver- Alicia De GuzmanTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff are not properly supervising residents resulting in elopements.
INVESTIGATION FINDINGS:
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On May 1, 2025, at 8:00 AM Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit at the above facility. LPA Kim met with Administrator (ADMIN) Julie Cornejo and explained the purpose of the visit. ADMIN Cornejo explained that they could not stay for the visit and Caregiver (CG) Alicia De Guzman will sign the report in behalf of the facility.

During today's visit, LPA Kim conducted a tour of the inside and outside of physical plant with CG De Guzman, and no concerns were observed. LPA Kim reviewed and obtained copies of four (4) resident record, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, and other pertinent records. LPA obtained residents roster, staff roster, and incident reports. LPA Kim conducted three (3) staff interviews and made an attempted interview with one (1) resident.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
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-20250422094955
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: CARE JANELLA
FACILITY NUMBER: 306006153
VISIT DATE: 05/01/2025
NARRATIVE
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Regarding Allegation: Staff are not properly supervising residents resulting in elopements

It is alleged that a resident has been reported missing four times within the last month and a half. RP was concerned of the facility’s security measures and its ability to provide adequate supervision and staffing for the residents.

The investigation revealed the following:

Based on record reviews, Resident I (R1) was admitted to the facility on March 4, 2025 and was discharged on April 21, 2025. R1 was diagnosed with Dementia and is not able to leave the facility unassisted according to their Physician’s Report dated March 4, 2025. The department received an Incident Reported dated April 20, 2025 indicating that R1 eloped from the facility. R1 was discovered missing again at 7:28 PM on the same day. It was not noted when R1 returned to the facility. Another Incident Report dated March 14, 2025 indicates R1 left the facility again at 12:40 pm. The caregiver (S2) noticed the window was left open. The resident was found at the local Dollar Tree and returned to the facility.

Based on interviews conducted, three out of three staff corroborated to the allegation. One resident could not confirm or deny the allegation. All staff confirmed the resident eloped from the facility on April 20, 2025. All staff stated the resident left the facility in the morning around 11:00 AM and was found at a Ford Dealership near the facility by the police. A staff member arrived at the Ford Dealership where the police was with the resident. The police asked the resident if they wanted to be accompanied by the staff or by the police back to the facility. The resident wanted to return to the facility with staff. The resident and staff were heading towards Dollar tree, where the resident hit the staff in the head twice, then ran away from the staff. Staff called 911. S2 and S3 state police found the resident and returned to the facility around 7:00 PM. Then the resident left the facility again around 7:30 PM. S2 and S3 state the police were notified that the resident was missing again and from orders of hospice, when resident returned that the resident needed to go to the hospital to be evaluated. Resident returned to the facility on April 21, 2025, around 2:30 AM. The police were notified by staff that the resident returned. Per orders of hospice, the Police accompanied the resident to the hospital to be evaluated.

Continued on LIC9099C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20250422094955
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: CARE JANELLA
FACILITY NUMBER: 306006153
VISIT DATE: 05/01/2025
NARRATIVE
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Based on LPA’s observations, the facility has four exits from the inside: the main entrance, the garage, the living area, and the resident room #4. All exits have an auditory device, but only the main entrance was operable. The living area and the garage auditory device were turned off, while the auditory device in resident room #4 was not working. S1 and S2 stated they did not know why the auditory devices were not working. LPA observed in room #2 where resident was staying the auditory device was taken off the window. S1 stated the resident would take it off and they just didn’t put it back on the window.

A review of Police Report #DR 25-014211 confirmed R1 eloped on April 20, 2025. No Police Report was obtained for the March 14, 2025 elopement incident.

Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff are not properly supervising residents resulting in elopements is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. One deficiency is being cited on the attached LIC9099D.

Exit interview was conducted a copy of the report, appeal rights, LIC9099D, and LIC811 were provided to Caregiver Alicia De Guzman.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20250422094955
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: CARE JANELLA
FACILITY NUMBER: 306006153
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87705(d)
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87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement...
This requirement is not met evidenced by:
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Licensee states they will fix bedroom #4 and remove bedroom #2 window auditory device from the room. Licensee states they will ensure all auditory devices are in operation. Proof of Correction evidence will be sent to CCLD via email to Edward.kim@dss.ca.gov by May 9, 2025.
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Based on observations and interviews, LPA observed four out of five auditory devices were not working: room #4 auditory device was not working, room #2 window auditory device was not in placed, and living area and garage auditory devices were turned off. 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4