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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003448
Report Date: 07/24/2025
Date Signed: 07/24/2025 12:39:11 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
07/11/2025 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250711095927
FACILITY NAME:FULLERTON ROSEWOOD ASSISTED LIVINGFACILITY NUMBER:
306003448
ADMINISTRATOR:JANE KIMFACILITY TYPE:
740
ADDRESS:411 E. COMMONWEALTH AVENUETELEPHONE:
(714) 441-0644
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:99CENSUS: 54DATE:
07/24/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jane KimTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Due to lack of supervision, resident physically assaulted another resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrived at the facility was greeted and granted entry by staff. LPA spoke with Jane Kim, Administrator, and explained the purpose of the visit.

Findings are based upon this investigation which included tour of the physical plant of the facility, resident/facility file review, and interviews conducted.

It is alleged due to lack of supervision resident physically assaulted another resident. Record review reflects that at the time of visit census was 54 residents and staff roster reflect there is three shifts AM, PM, and NOC with 2-4 carestaff assigned per shift. An unusual incident report LIC621 received on July 10, 2025, resident

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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 2
Control Number 22-AS-20250711095927
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: FULLERTON ROSEWOOD ASSISTED LIVING
FACILITY NUMBER: 306003448
VISIT DATE: 07/24/2025
NARRATIVE
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(R1) and resident (R2) had an altercation with each other in the apartment/bedroom hallway on July 5, 2025. Records for R1 and R2 revealed that they are alert, do not require any ambulatory assistance, functional capabilities or physical services, do not require 1:1 ratio care, and do not require 24 hour care. Interviews with 2 of 2 staff stated that neither resident required 1:1 ratio care or 24 hour care and that incident happened in a common space of the facility and staff immediately intervened once they were notified of the incident. Since neither requires such care it is not uncommon for incidents to occur in common spaces of the facility or where staff is not around. Staff stated they immediately applied de-escalation methods and this was the first incident involving R1 and R2 and since incident they have not had any further incidents amongst R1 and R2. Staff stated that they have taken adequate measures to address the situation. Interviews with 6 of 6 residents stated that staff are good at assisting them when they need help and get help almost immediately. They have never had issues with not getting assistance and there is always staff around to help.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with the Administrator and a copy of this LIC9099 report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
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