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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603476
Report Date: 01/15/2026
Date Signed: 01/15/2026 03:12:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2026 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260107152642
FACILITY NAME:LA MIRADA VILLA FOR THE ELDERLYFACILITY NUMBER:
198603476
ADMINISTRATOR:DE HONOR, ELIZAFACILITY TYPE:
740
ADDRESS:15005 LA FONDA DR.TELEPHONE:
(714) 342-8236
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 6DATE:
01/15/2026
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:William Del Rio, StaffTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not administer residents’ medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced and met with staff. The purpose of the visit was explained.

LPA toured the facility, obtained copies of the resident roster, reviewed residents’ files and their medications. LPA interviewed the Administrator via telephone, two (2) Staff, five (5) Residents, and family members.

The investigation revealed the following:
Allegation – Staff did not administer residents’ medications as prescribed. Per the administrator and staff interviewed, the residents are given their medications as prescribed. The facility uses a Medication Administration Records (MARs) to record the medications when given. Five (5) of the residents interviewed stated they are taking their medications daily and on time.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
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 5
Control Number 28-AS-20260107152642
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LA MIRADA VILLA FOR THE ELDERLY
FACILITY NUMBER: 198603476
VISIT DATE: 01/15/2026
NARRATIVE
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LPA reviewed all six (6) of the residents’ medications and discrepancies were observed for three (3) out of the six (6). Resident #2’s medication (Quetiapine Fumarate 50MG) and Resident #3’s medications (Docusate Sodium100MG and Senna 8.6MG) are not given as indicated on the MAR log. Per staff, they were instructed not to give them either by the family member or nurse. However, there were no physician’s order for the instruction. In addition, Resident #4’s medication (Acetaminophen 500MG) was not given at noon time consistently.

Based on LPA observations, interviews conducted, and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Correction was reviewed and developed with the administrator via telephone. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20260107152642
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LA MIRADA VILLA FOR THE ELDERLY
FACILITY NUMBER: 198603476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
01/16/2026
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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The licensee shall submit a plan to address the medication discrepancies for Residents #2, #3, and #4. In addition, an in-service training regarding medications shall be provided and log shall be submitted to LPA by 1/16/26.
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Based on medication review, 3 out of the 6 residents were not receiving their medications as prescribed by the physician which poses an immediate health and safety risk to residents 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: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/07/2026 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260107152642

FACILITY NAME:LA MIRADA VILLA FOR THE ELDERLYFACILITY NUMBER:
198603476
ADMINISTRATOR:DE HONOR, ELIZAFACILITY TYPE:
740
ADDRESS:15005 LA FONDA DR.TELEPHONE:
(714) 342-8236
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:6CENSUS: 6DATE:
01/15/2026
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:William Del Rio, StaffTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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2
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5
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9
Staff are falsifying resident's records.
INVESTIGATION FINDINGS:
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2
3
4
5
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7
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9
10
11
12
13
Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced and met with staff. The purpose of the visit was explained.

LPA toured the facility, obtained copies of the resident roster, reviewed residents’ files and their medications. LPA interviewed the Administrator via telephone, two (2) Staff, five (5) Residents, and family members.

The investigation revealed the following:
Allegation - Staff are falsifying resident's records. It is alleged that a doctor requested medical records from the facility, but the facility did not respond to the request in a timely manner and were not honest about the information they provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20260107152642
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LA MIRADA VILLA FOR THE ELDERLY
FACILITY NUMBER: 198603476
VISIT DATE: 01/15/2026
NARRATIVE
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 LPA interviewed the administrator and staff regarding this allegation. The administrator stated that no doctors have contacted her to inquire or obtain documents for any of the residents. Administrator also stated that staff are aware that they should not be providing any information without notifying her or receiving an approval. LPA interviewed two (2) staff who stated that no doctors or family members have requested any records or ask for specific information of a resident. One of the Staff recalled a nurse contacting the facility last week to inquired if someone called about Resident #1. Staff responded no and there was no other information requested. Staff interviewed denied falsifying any residents’ records. LPA interviewed family members who stated they have not requested any of the residents’ documents and have not encountered staff providing inaccurate information. LPA reviewed three (3) residents’ files. The files appear complete, and LPA did not observe any information crossed out or appeared altered. Based on the information gathered, there is insufficient evidence to prove that staff are falsifying residents’ records.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Staff W. Del Rio. A copy of this report, along with the appeal rights, was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5