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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603476
Report Date: 02/05/2026
Date Signed: 02/05/2026 12:57:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/30/2026 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260130122548
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: 5DATE:
02/05/2026
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:William Del Rio - CaregiverTIME COMPLETED:
12:57 PM
ALLEGATION(S):
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Staff does not administer resident’s medication as prescribed
Staff does not provide resident with oxygen
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced complaint visit to address the allegations listed above. LPA met with William Del Rio, caregiver for the facility, and explained the purpose of the visit. Administrator Eliza De Honor was notified of the visit by phone call however was not able to make the visit to the facility.

The investigation consisted of the following: LPA conducted a tour of the facility, interviewed Staff #1 - 2 (S1 - S2), Residents #1 - 5 (R1 - R5), and also reviewed the medications along with the medication orders for R1 - R5.

The investigation revealed the following: In regards to the allegation that "Staff does not administer resident's medication as prescribed, it was alleged that one of the residents of the facility had not received their medications for two (2) days in the month of January 2026.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026
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 3
Control Number 28-AS-20260130122548
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 02/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2026
Section Cited
CCR
87465(a)(4)
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(a) A plan for incidental medical and dental care shall be developed by each facility. (...) (4) The licensee shall assist residents with self-administered medications as needed.

This regulation is not met as evidenced by:
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The licensee shall submit a plan to address the medication discrepancies for R1 - R2. In addition, an in-service training regarding medications shall be provided and log shall be submitted to LPA by the POC due date.
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Based on staff/client interviews and a review of medication records, LPA determined that facility staff did not administer medications as prescribed or obtained discontinue orders for 2 out of 5 resdients (R1 - R2), which poses an immediate health and safety threat to residents in care.
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Type B
02/26/2026
Section Cited
CCR
87618(b)(1)
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(b) In addition to Section 87611(b), the licensee shall be responsible for the following: (1) Monitoring of the resident's ongoing ability to operate the equipment in accordance with the physician's orders.

This regulation is not met as evidenced by:
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Administrator is to obtain a physician order of oxygen administration for R1 and provide it to LPA, along with a plan with how the facility will ensure the order is followed to LPA by the POC due date.
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Based on observation, staff/client interviews and a review of physician orders, LPA determined that facility staff did not monitor resident's ability to operate oxygen equipment and could not provide an order for 1 out of 5 residents (R1), which poses a potential health and safety threat 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: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20260130122548
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LA MIRADA VILLA FOR THE ELDERLY
FACILITY NUMBER: 198603476
VISIT DATE: 02/05/2026
NARRATIVE
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Based on resident interviews, one (1) out of five (5) corroborated the allegation. One resident explained they were provided a nighttime medication twice, wen they are supposed to be provided it only once, on accident by facility staff approximately two (2) weeks ago. No other residents corroborated the allegation. In interviews with staff, none of them corroborated the allegation. The staff stated that they are providing medications to all residents according the physician orders and that there has not been any discrepancies. During medication or R1's medication, it was observed that their morning medication for Furosemide 20 MG is supposed to be given twice, however only one (1) was distributed and the second was found still in the bubble pack. In addition, Nystatin cream and Triamcinolone is indicated as cycle medications and were not present. Facility staff stated that they have been discontinued but their is no discontinue order. In addition C2's Azithromycin 250 MG medication was not being given due to being put on a hold by a nurse according to staff, however there is no order for this. C2 also had Ensure and Ketaconazole orders that were said to have been discontinued, however there are no discontinue orders, and C2 was also out of their Vitamin A & D ointment.

In regards to the allegation that "Staff does not provide resident with oxygen," it is alleged that R1 is supposed to be on continued oxygen, however they were not given oxygen for two (2) days in the month of January 2026, and that staff turn off the oxygen machine due to concerns about setting off the facility smoke alarm. During interviews with the residents, none of them corroborated the allegation. All residents denied there had been any issues with oxygen administration. During interviews with staff, none of them corroborated the allegation as well. Staff stated that R1 that they do not turn off the oxygen for any resident, and that they are not sure what R1's oxygen order is however they believe it is not 24/7. Another staff stated that R1 only ceases to use their oxygen when using the restroom and for meals. During LPA's interview with R1 in the living room of the facility, R1 did not have their oxygen machine turned on. In addition, the facility staff were not able to provide a physician order for R1's oxygen use.

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 LIC9099D.

Exit interview was held, and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3