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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001615
Report Date: 10/15/2025
Date Signed: 10/15/2025 07:29:40 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/28/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20250428152534
FACILITY NAME:MEISON LA PAZ ELDERLY CARE HOMEFACILITY NUMBER:
306001615
ADMINISTRATOR:MIGUEL PEREZFACILITY TYPE:
740
ADDRESS:24332 TWIG STREETTELEPHONE:
(949) 454-6184
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
07:05 AM
MET WITH:Efrain MatheusTIME COMPLETED:
07:50 AM
ALLEGATION(S):
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Staff did not provide medical staff with resident’s DNR
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, the department toured the facility and interviewed staff and witness. Regarding the allegation that Staff did not provide medical staff with resident’s DNR, the investigation revealed the following: R1 had a “Do Not Resuscitate (DNR)” order effective April 28, 2024. On April 21, 2025, R1 started to choke on chopped pineapple at approximately 4:50 PM. Staff immediately started the Heimlich maneuver which was unsuccessful due to pieces of the pineapple being stuck in R1’s throat. 911 was called at 4:59 PM with paramedics responding at 5:04 PM. When the paramedics arrived, R1 was initially pulseless, apneic, asystole with pale skin. R1’s pupils were fixed and dilated, the primary impression of which was cardiac arrest per Orange County Fire Authority Incident Report. Paramedics were able to get a pulse, and resident was transferred to Saddleback Memorial Hospital where resident subsequently passed on April 24, 2025, with a cause of death listed as acute respiratory failure with Hypoxia and pneumonia due to CONTINUED ON LIC 9099C DATED 10/15/2025
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
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 6
Control Number 22-AS-20250428152534
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MEISON LA PAZ ELDERLY CARE HOME
FACILITY NUMBER: 306001615
VISIT DATE: 10/15/2025
NARRATIVE
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inhalation of secretions. Staff 1 reported they provided the DNR to the paramedics when they responded. Administrator stated the paramedics stated that R1 had to be transported to the hospital and R1’s family was upset that 911 had been called. Per Orange County Fire Authority Incident Report, there is no mention of DNR paperwork being provided and/or knowledge of R1’s DNR status. Records obtained from Saddleback Hospital, do not show that documentation of DNR was received by the paramedics. Hospital records document that the hospital became aware of DNR status from R1’s spouse who verbally advised them of R1’s DNR upon arriving at the hospital. Based on record review and interviews conducted, 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, Chapter 8) are being cited on the attached LIC 9099D. Exit interview conducted and a copy of the report provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20250428152534
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MEISON LA PAZ ELDERLY CARE HOME
FACILITY NUMBER: 306001615
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2025
Section Cited
CCR
87468.1(a)(16)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services. This requirement is not met as evidenced by:
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Licensee to conduct an in-service on the process of DNR and first responders and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure resident was able to reject medical care. R1 had a "DNR" on file which was not provided to first responders. This 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/28/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20250428152534

FACILITY NAME:MEISON LA PAZ ELDERLY CARE HOMEFACILITY NUMBER:
306001615
ADMINISTRATOR:MIGUEL PEREZFACILITY TYPE:
740
ADDRESS:24332 TWIG STREETTELEPHONE:
(949) 454-6184
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
07:05 AM
MET WITH:TIME COMPLETED:
07:50 AM
ALLEGATION(S):
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Staff did not properly prepare resident’s food resulting in resident to choke
Staff unable to communicate with resident due to language barrier
Staff force fed resident
Resident sustained skin tear while in care due to neglect
Staff not administering resident's medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, the department toured the facility and interviewed staff and witness. Regarding the allegation that staff did not properly prepare resident’s food resulting in resident to choke, the investigation revealed the following: Resident 1 (R1) was admitted into the facility on January 22, 2025, with a diagnosis of Parkinson’s Disease and Dementia per physician report dated January 06, 2025. Per pre-appraisal dated December 24, 2024, R1 was able to self-feed with staff assisting by cutting up the food. On April 21, 2025, R1 started to choke on chopped pineapple at approximately 4:50 PM. Staff immediately started the Heimlich maneuver which was unsuccessful due to pieces of the pineapple being stuck in the resident’s throat. 911 was called at 4:59 PM with paramedics responding at 5:04 PM. When the paramedics arrived, R1 was initially pulseless, apneic, and asystole with pale skin. R1’s pupils were fixed and dilated, the primary impression of which was cardiac arrest per Orange County Fire Authority Incident Report. Paramedics were able to get a pulse, and R1 was transferred to Saddleback Memorial Hospital where they subsequently passed on April 24, 2025.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
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 6
Control Number 22-AS-20250428152534
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MEISON LA PAZ ELDERLY CARE HOME
FACILITY NUMBER: 306001615
VISIT DATE: 10/15/2025
NARRATIVE
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Paramedics were able to get a pulse, and R1 was transferred to Saddleback Memorial Hospital where they subsequently passed on April 24, 2025. The cause of death was listed as Acute Respiratory Failure with Hypoxia and Pneumonia due to inhalation of secretions. Per Interview with Administrator, R1 would self-feed but due to their difficulty swallowing, R1’s food was always cut up in about .5 inches increments and was monitored by staff while eating. R1 could eat on their own but was very slow in the process. R1 did not want to be fed by staff and preferred to self-feed. Home Health notes showed R1 did not have food restrictions. Administrator as well as staff stated R1 always had thick-it mixed in with fluids due to the risk of choking. Three out of three staff state R1’s food was always cut up and resident was monitored while eating. Although R1 did choke on food prepared, it remains unclear if choking was caused due to the food not being prepared properly.
Regarding the allegation that staff force fed resident, the investigation revealed the following: Per pre-appraisal dated December 24, 2024, and physician report dated January 06, 2025, R1 was able to self-feed with staff cutting up the food. R1 was on soft food diet as well. Nursing notes indicated resident had no food restrictions. Three out of three staff deny force feeding R1 and state they were able to self-feed. Staff reported R1 would take a long time to eat and sometimes would fall asleep while eating but the staff stated allowing R1 the time to feed themself. R1’s family member would provide specific food for R1 and staff would allow the resident time to finish. R1’s family member indicated observing facility staff force the resident to eat.
Regarding the allegation that Resident sustained skin tear while in care due to neglect, the investigation revealed the following: Per physician report dated January 06, 2025, R1 is diagnosed with Parkinson’s Disease and Dementia. Physician report shows R1 was admitted with a foot heel ulcer. Prior to R1 moving into the facility, R1 was seen on December 30, 2024, for a non-healing left heel ulcer initiated by a pressure injury and complicated by Dementia. R1 was seen at Saddleback Memorial Center for the condition. While admitted, R1 received wound care, in which the diagnosis was a Stage III. After selective debridement, the ulcer was then diagnosed as a Stage II at the time R1 was admitted to the facility. Resident was receiving wound care from Accent Care Home Health as well as Providence Palliative Care from December of 2024 through April of 2025. Nursing notes from Accent Home Health show that R1 was being seen for wound care to left and right heel ulcers approximately every seven days. Accent Home Health Notes showed instructions for elevating R1’s heels and that staff reported following instructions. The Administrator stated R1 had received a skin tear after R1 put their arm out as they were passing through a doorway. Home Health nursing notes show R1 was being treated for the skin tear as well. Although R1 did sustain a skin tear, it remains unclear if the skin tear was caused due to neglect.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 22-AS-20250428152534
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MEISON LA PAZ ELDERLY CARE HOME
FACILITY NUMBER: 306001615
VISIT DATE: 10/15/2025
NARRATIVE
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Regarding the allegation that staff unable to communicate with resident due to language barrier, the investigation revealed the following: Two out of two staff and two out of two residents deny any issues with communication. Two out of two residents state having no issues communicating with the staff even though English is a second language. Both residents state staff are attentive and communicative to their needs. Staff state being able to communicate with the residents without challenge. LPA interviewed both staff without any translation services. Staff 1 demonstrated knowledge of calling for emergency services and what information to provide.

Regarding the allegation that staff not administering resident's medication as prescribed, the investigation revealed the following: S1 is primarily responsible for medication administration. S1 states providing R1's medication four times a day before meals as instructed in the physician order. LPA reviewed the medication order for Carbidopa and Levodopa for Parkinson's Disease four times a day at breakfast, lunch, dinner, and nighttime. Facility does not use a medication administration record for routine medications. Two out of two residents state knowing what their medications are and they are being administered per physician order.

Based on records reviewed and interviews conducted, the department is unable to corroborate the above allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and copy of the report was provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6