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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006303
Report Date: 04/24/2024
Date Signed: 04/24/2024 04:51:06 PM

Unfounded


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
04/17/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240417083208
FACILITY NAME:CARE SAINT JACOBFACILITY NUMBER:
306006303
ADMINISTRATOR:AMORSOLO, LEONORA CHERYLLFACILITY TYPE:
740
ADDRESS:4110 E JORDAN AVETELEPHONE:
(714) 289-1946
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 6DATE:
04/24/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Julie Cornell, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Staff are mismanaging resident medication
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the allegation listed above. LPA was greeted and granted entry by caregiving after introducing himself and stating the reason of the visit. Administrator Julie Cornejo was notified of the visit by telephone and agreed to review the final report with LPA prior to authorizing her caregiving staff to sign on her behalf.

LPA accompanied by caregiver conducted a tour of the physical plant. LPA conducted private interviews with the six residents currently in care at the facility and reviewed the medication orders and medication administration records for all six residents. LPA assisted by facility staff also verified the content of the medication central storage for residents R1 and R2 which were both observed to be consistent with the refilling cycle and accurate dispensation to the residents in question.
CONTINUED ON FORM LIC9099-C

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
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 2
Control Number 22-AS-20240417083208
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 SAINT JACOB
FACILITY NUMBER: 306006303
VISIT DATE: 04/24/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099
Based on the observation of the facility's medication administration records, physician orders on file as well as interviews conducted with all six residents currently admitted at the facility, LPA was unable to find any evidence that Staff are mismanaging resident medication. The allegation is therefore determined to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. The Department has investigated this complaint.

A copy of this report is being reviewed with facility representative via telephone and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2