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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003397
Report Date: 10/27/2025
Date Signed: 10/27/2025 04:58:09 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
10/22/2025 and conducted by Evaluator Edward Kim
COMPLAINT CONTROL NUMBER: 22-AS-20251022110928
FACILITY NAME:BELMONT GUESTS RETREAT IFACILITY NUMBER:
306003397
ADMINISTRATOR:ELIZABETH MULLINSFACILITY TYPE:
740
ADDRESS:6541 FAIRLYNN BLVD.TELEPHONE:
(714) 970-0247
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 2DATE:
10/27/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator- Elizabeth MullinsTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility refused to provide refund after resident passed away.
INVESTIGATION FINDINGS:
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On October 27, 2025, at 9:00 AM, Licensing Program (LPA) Edward Kim conducted an unannounced initial complaint visit at the facility. LPA Kim met with Administrator (ADMIN) Elizabeth Mullins and explained the purpose of the visit.

During today's visit, LPA Kim conducted a tour of the indoor and outdoor physical plant with ADMIN Mullins. LPA Kim reviewed and obtained copies of the following records for Resident #1 (R1): Admission Agreement, Identification and Emergency Information, Physician's Report, Appraisal Needs and Services Plans, and other pertinent records. LPA reviewed and obtained the Personnel Record, Resident Roster, and other pertinent records. LPA Kim also conducted one (1) staff interview.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
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-20251022110928
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: BELMONT GUESTS RETREAT I
FACILITY NUMBER: 306003397
VISIT DATE: 10/27/2025
NARRATIVE
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The investigation revealed the following:

Allegation: Facility refused to provide refund after resident passed away

It is alleged that the facility did not issue a refund to the individual or entity contractually responsible for R1 payment. The individual requested a refund for the remaining days of October. R1 passed away on October 7, 2025, and an individual for R1 removed all of their belongings on October 8, 2025.

Based on an interview conducted, Staff #1 confirmed the allegation that they did not process a refund for the individual responsible for R1’s payment. S1 stated that the reason they did not issue a refund is because the Admission Agreement stated there are no refunds for the first month’s rent. S1 stated that R1 passed away on October 7, 2025, and removed personal belongings on October 8, 2025. Hospice picked up the medical equipment supplied on October 9, 2025.

Based on record review, a copy of a check dated September 22, 2025, revealed a payment for R1 was made for $5500 and was received by the facility and per interview with S1, the facility will send a refund to R1’s responsible party.

Based on observation, LPA verified that R1’s room was empty, and all R1’s personal property, belongings, and hospice equipment were no longer inside of the room.

Based on information gathered, there is sufficient evidence to corroborate the above allegation.

Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility refused to provide refund after resident passed away is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. A deficiency is being cited on the attached LIC9099D.

Exit interview was conducted, and a copy of the report, LIC9099D, LIC811, and the appeal rights were provided to Administrator Elizabeth Mullins.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20251022110928
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: BELMONT GUESTS RETREAT I
FACILITY NUMBER: 306003397
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2025
Section Cited
CCR
87507(g)(5)(A)
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87507(g)(5)(A) Refund conditions. (A)Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652.
This requirement is not met evidenced by:
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Licensee states they will pay a refund of $3725.80 to R1’s Responsible Party who paid the October payment and will send proof of payment to CCLD via email to Edward.kim@dss.ca.gov by POC due date November 10, 2025.
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Based on record review, interview, and observation, the licensee did not comply with the section cited above. A refund was not issued to R1’s responsible party who paid for the month of October. This poses a potential health and safety risk to persons 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3