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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003060
Report Date: 11/19/2025
Date Signed: 11/19/2025 03:13:31 PM

Unsubstantiated


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
12/22/2021 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20211222122257
FACILITY NAME:WEST GLENN MANORFACILITY NUMBER:
306003060
ADMINISTRATOR:ROSARIO NAZARENOFACILITY TYPE:
740
ADDRESS:7242 WESTMINSTER BLVD.TELEPHONE:
(714) 898-2131
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:98CENSUS: 85DATE:
11/19/2025
UNANNOUNCEDTIME BEGAN:
12:42 PM
MET WITH:Rosario Nazareno, administrator
Brian Nazareno, licensee		TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff do not properly groom a resident while in care

Resident is being over fed while in care

Staff are not addressing a resident's medical conditions while in care

Staff are not meeting a resident's incontinence needs
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 following up on the investigation of the four allegations listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Administrator Rosario Nazareno was present on the premises and presented with the allegations.

An initial investigation visit was conducted on December 29, 2021. During the visit, LPA Jenifer Tirre toured the premises. Residents were observed relaxing in bedrooms and playing bingo in dining room. LPA conducted interviews with staff and residents at time of visit. LPA requested pertinent documents.

During the present visit, LPA conducted five additional staff and five resident interviews and reviewed resident records for resident R1. LPA also requested the facility's current resident census and staff roster.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
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-20211222122257
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: WEST GLENN MANOR
FACILITY NUMBER: 306003060
VISIT DATE: 11/19/2025
NARRATIVE
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CONTINUED FROM FORM LIC9099
Resident R1 was admitted to the facility on 03/31/2007 and discharged from West Glenn Manor in May 2024 after he was assessed to require a higher level of care. R1 was on the Assisted Living Waiver. Based on multiple physician reports reviewed, the latest of which was established on February 23, 2022, R1 was ambulatory and able to leave the facility unassisted, with a primary diagnosis of Major Depressive Disorder. R1 was not assessed to have any form of Major Neurocognitive Disorder at the time.

Regarding the allegation that Staff do not properly groom a resident while in care, the following has been concluded: Based on multiple staff and witness interviews, it was determined that R1 required extensive assistance with toileting and grooming care. Staff interviews conducted all confirmed that facility staff was providing R1 with assistance with these activities of daily living. R1 was stated to have grown reticent to receive showers or change clothing during the final years of his admission at the facility, requiring additional prompting and occasionally being stated to have yelled at staff attempting to provide assistance.

Regarding the allegation that Resident is being over fed while in care, the following has been concluded: Based on a wide majority of statements gathered, it was determined that facility staff was providing meal supervision to R1 while on the premises, however meals at the day program attended were not as closely monitored, resulting in R1 allegedly requesting to finish the plates of other program clients. Additionally, R1 was found to procure food in the community on a frequent basis as well. Weight gain observed during the resident's admission can therefore not be directly attributed to staff failing to supervise R1 adequately.

Regarding the allegation that Staff are not addressing a resident's medical conditions while in care, the following has been concluded: A review of the resident's assessments and charting notes, frequent follow-ups with R1 primary care provider, behavioral specialist as well as hospitalization reports appears to document that medical conditions experienced by R1 were monitored and medical attention was sought whenever needed.

CONTINUED ON FORM LIC9099-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20211222122257
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: WEST GLENN MANOR
FACILITY NUMBER: 306003060
VISIT DATE: 11/19/2025
NARRATIVE
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CONTINUED FROM FORM LIC9099-C
Regarding the allegation that Staff are not meeting a resident's incontinence needs, the following has been concluded: Based on staff interviews and assessments reviewed, it was determined that R1 was occasionally experiencing diarrhea episodes which required the use of incontinence supplies, however it was not a continuous need. Charting notes and physician visit reports dated December 2021 indicate that R1 suffered more frequent episodes while at program which appear to be related to R1's food intake while out of the facility. It cannot be confirmed whether the reported occurrence of a soiled diaper happened during one of these episodes rather than as a result of facility staff failing to ensure R1 was changed in due time.

As a result, all four allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is no preponderance of the evidence to prove that the alleged violations occurred.

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

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3