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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002621
Report Date: 01/23/2026
Date Signed: 01/23/2026 10:54:24 AM

Unsubstantiated


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
09/21/2022 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20220921120629
FACILITY NAME:CONCORDIA GUEST HOME - 2FACILITY NUMBER:
306002621
ADMINISTRATOR:MICHAEL O ROACHFACILITY TYPE:
740
ADDRESS:212 JUNIPER STREETTELEPHONE:
(714) 671-6085
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 4DATE:
01/23/2026
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Concordia "Cora" Velasco - Licensee TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
Resident eloped from the facility
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the faciliy by staff and explained the reason for the visit.

The Department received a complaint on 09/21/2022 and the initial 10 day visit was conducted by LPA Gutierrez on 09/22/2022. LPA Gutierrez interviewed staff and residents. LPA Mendivil obtained copies of LIC 602 Physician's Report dated 07/14/2020.

It was reported that Resident 1 (R1) eloped from the facility. Licensee Concordia "Cora" Velasco stated that R1 walked out of the door and was a few houses down from the facility. Per review of LIC 602 Physician's Report dated 07/14/2020 the resident is diagnosed with dementia and based on LIC 602 is able to leave the facility unassisted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
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 2
Control Number 22-AS-20220921120629
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: CONCORDIA GUEST HOME - 2
FACILITY NUMBER: 306002621
VISIT DATE: 01/23/2026
NARRATIVE
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Based on interview with Licensee Cora stated residents are able to leave the facility by themselves if the LIC 602 Physician's Report states the resident is able to leave unassisted. Licensee reported that if a resident is not able to leave unassisted they will let the resident out with a caregiver or a family member.

Therefore based on the preponderance of evidence through records reviewed and interviews the allegation Resident eloped from the facility is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

No deficiencies cited.
An exit interview was conducted and a copy of this report and confidential names list was provided
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2