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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006220
Report Date: 06/04/2024
Date Signed: 06/04/2024 12:08:45 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
05/28/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240528111223
FACILITY NAME:MARY'S LOVING CARE AFACILITY NUMBER:
306006220
ADMINISTRATOR:HAN, XUFACILITY TYPE:
740
ADDRESS:341A 16TH PLACETELEPHONE:
(949) 200-9378
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:6CENSUS: 5DATE:
06/04/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Mary You- House ManagerTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Staff is operating beyond the scope of the license.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of intiiating the 10-day complaint investigation into the above allegation. LPA was greeted and granted entry by Caregiver Carolina Flores Perez and stated the purpose of the visit. House Manager Mary (Xiaofen) You arrived at the facility approximately 10:30am, and LPA advised Administrator Emma (Xu) Han by telephone of the visit. On today's date, LPA observed five (5) residents in care and two (2) staff on duty. Resident #1 (R1) was observed to be sitting and singing on the recliner chair in the living room playing with their toys. During the course of the investigation, LPA interviewed two staff and obtained copies of the following pertinent documentation: Resident Roster, Face Sheets, Physician's Reports for all residents in addition to the Preplacement Appraisal Information, Care Plan, and Admission Agreement for R1.

The investigation revealed the following: It is alleged that the staff is operating beyond the scope of the license. [Continued on LIC9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
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 3
Control Number 22-AS-20240528111223
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: MARY'S LOVING CARE A
FACILITY NUMBER: 306006220
VISIT DATE: 06/04/2024
NARRATIVE
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Per review of the Identification and Emergency Information (LIC601), R1 is under sixty (60) years old and does not meet the age requirement. Two out of the two staff interviews indicated that R1 was previously attending a group home vendored by the Regional Center of Orange County and was removed from their previous group home. It is determined that licensee is not operating within the limitations specified on the license.

Therefore, based on the observation, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff is operating beyond the scope of the license is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. A deficiency is being cited on the attached LIC9099-D.

At 11:54am, an exit interview was conducted by telephone with Administrator Emma Han and in person with House Manager Mary You, and a copy of this report was provided along with the LIC9099-C, LIC9099-D, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240528111223
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: MARY'S LOVING CARE A
FACILITY NUMBER: 306006220
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2024
Section Cited
CCR
87204(a)
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87204 Limitations - Capacity and Ambulatory Status (a) "A licensee shall not operate a facility beyond the conditions and limitations specified on the license..."

This requirement was not met as evidenced by:
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Administrator stated that they will move out and/or relocate R1 immediately and to submit an age exception request to the Department (should the licensee desires to continue to provide care) along with the Acknowledgement of Understanding of the said deficiency to LPA via email by POC due date.
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Based on observation, interviews, and record review, R1 does not meet the age requirement specified on the license which poses an immediate risk to the Heath, Safety, or Peronal 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: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3