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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006317
Report Date: 10/25/2023
Date Signed: 10/25/2023 12:52:59 PM

Unsubstantiated


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
08/04/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230804111101
FACILITY NAME:FAITHFUL HOME OF ROSSMOOR, AFACILITY NUMBER:
306006317
ADMINISTRATOR:MUNROE, ALICIAFACILITY TYPE:
740
ADDRESS:2851 BOSTONIAN DRTELEPHONE:
(714) 300-8055
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY:6CENSUS: 5DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rudy Ignacio, House managerTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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9
Staff locked resident in their room.

Staff administered medication that was not prescribed to resident.
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 following up on the investigation of the two allegations listed above. LPA was greeted and granted entry by facility staff after stating the reason for the visit. House Manager Rudy Ignacio was notified of the visit via telephone and arrived later to assist with the visit.

An initial complaint investigation visit was conducted on August 8, 2023. A tour of the facility's physical plant was conducted along with a review of resident records and an interview with the administrator. A follow-up visit was later held on August 25, 2023 with 4 staff interviews completed. Additional witness interviews were also conducted via telephone during the investigation.

A total of five resident interviews were finally attempted or conducted during the present visit.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
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-20230804111101
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: FAITHFUL HOME OF ROSSMOOR, A
FACILITY NUMBER: 306006317
VISIT DATE: 10/25/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099
Regarding the allegation that Staff locked resident in their room, the following has been concluded: Based on observation made in the physical plant, records reviewed and interviews conducted, LPA could not sufficiently evidence that any of the facility's door were equipped with a lock or a locking latch at the time of the allegations. Staff, witnesses and residents interviewed denied any knowledge of a resident ever being locked in their room. The allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did occur.

Regarding the allegation that Staff administered medication that was not prescribed to resident, the following has been concluded: Based on evidence gathered, medication reviewed, records reviewed and interviews conducted, it could not be sufficiently evidenced that medication belonging to another resident was at any point administered to another resident for the purpose of managing their behavior. All medication observed during the three site visits were prescribed to a resident currently admitted and verified as such. However, in the presence of a photograph of medication on which the label had been marked off with a marker, the Department could not sufficiently ascertain that the allegation did not occur either. As a result, the allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did occur. A Technical Assistance Advisory Note is however issued to remind licensee that per Title 22 Regulations "No persons other than the dispensing pharmacist shall alter a prescription label".

An exit interview was conducted 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: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2