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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001028
Report Date: 07/17/2025
Date Signed: 07/17/2025 04:42:47 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
07/16/2025 and conducted by Evaluator Kevin Saborit-Guasch
COMPLAINT CONTROL NUMBER: 22-AS-20250716093842
FACILITY NAME:GOOD SAMARITAN IIFACILITY NUMBER:
306001028
ADMINISTRATOR:CAMBIO, SUSAN & LEOFACILITY TYPE:
740
ADDRESS:26852 LA SIERRATELEPHONE:
(949) 367-1228
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 2DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Susan Cambio, Administrator
Leo Cambio, Administrator (via phone)		TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Licensee is not providing resident's records to their responsible party as required.
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 initiating the investigation into the allegation listed above. LPA was greeted and granted entry by facility administrator Susan Cambio after stating the purpose of the visit.

LPA conducted an interview via telephone with administrator Leo Cambio who stated that a copy service had come in person to the facility to obtain duplicates of the available records for resident R1. R1 moved out of the facility without notice on or around April 12, 2025, and the records were relocated to a central administrative location at the time. At the time of the visit from the copy service, the only files available that could be located by facility staff were the hospice records and not the resident records. At the time of the present visit, administrator is still unable to account for the location of the requested records.

CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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-20250716093842
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: GOOD SAMARITAN II
FACILITY NUMBER: 306001028
VISIT DATE: 07/17/2025
NARRATIVE
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CONTINUED FROM LIC9099
Regarding the allegation that Licensee is not providing resident's records to their responsible party as required, the following has been concluded: After an initial request dated May 21, 2025 and after a visit from a copy service was scheduled on June 9, 2025, the facility was only able to provide hospice records for resident R1 to their responsible party. Other records such as the resident's admission agreement, physician report and individual needs assessments could not be located and/or provided at that time. They have not been located or provided since.

As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type B deficiency is cited on an attached form LIC9099-D.

An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250716093842
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: GOOD SAMARITAN II
FACILITY NUMBER: 306001028
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2025
Section Cited
CCR
87468.2(a)(19)
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Per CCR 87468.2(a)(19): "residents in (...) shall have all of the following personal rights: To have prompt access to review all of their records and to purchase photocopies of their records. (...) records shall be provided within two (2) business days". This requirement is not met as evidenced by:
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Licensee will continue efforts to locate the records and ensure that they are provided to the responsible party as soon as possible.

Proof of submission to be submitted to LPA before the plan of corrections due date.
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The initial request for request was made on May 21, 2025. As of the present visit, records have not been provided to R1's responsible party in full, which constitutes a potential risk to the health, safety and personal rights of individuals 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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3