<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004176
Report Date: 10/09/2025
Date Signed: 10/09/2025 12:51:25 PM

Unfounded


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
07/13/2021 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210713111719
FACILITY NAME:SAM'S HOMECAREFACILITY NUMBER:
306004176
ADMINISTRATOR:JUHAYNA DIAZFACILITY TYPE:
740
ADDRESS:18900 SEABISCUIT RUNTELEPHONE:
(714) 312-0054
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 4DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Juhayna Diaz, administrator (via phone)
Rosallie Gabriel, house manager		TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not notify authorized representative about change of resident health condition.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 two allegations listed above. LPA was greeted and granted entry by facility staff after introducing himself, stating the purpose of the visit and listing the allegations investigated. Administrator Juhayna Diaz was notified of the visit via telephone and gave house manager staff permission to sign the report after being informed of the findings.

The initial complaint investigation visit was conducted by LPA Kathrina Chin on July 19, 2021. During the visit, licensing staff interviewed staff, residents and reviewed and obtained documentation. Additional witness interviews were conducted during the investigation.

During the present visit, LPA requested additional documentation and interviewed staff members present.
CONTINUED ON FORM LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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 4
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
07/13/2021 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210713111719

FACILITY NAME:SAM'S HOMECAREFACILITY NUMBER:
306004176
ADMINISTRATOR:JUHAYNA DIAZFACILITY TYPE:
740
ADDRESS:18900 SEABISCUIT RUNTELEPHONE:
(714) 312-0054
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 4DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Juhayna Diaz, administrator (via phone)
Rosallie Gabriel, house manager		TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical attention to resident in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 two allegations listed above. LPA was greeted and granted entry by facility staff after introducing himself, stating the purpose of the visit and listing the allegations investigated. Administrator Juhayna Diaz was notified of the visit via telephone and gave house manager staff permission to sign the report after being informed of the findings.

The initial complaint investigation visit was conducted by LPA Kathrina Chin on July 19, 2021. During the visit, licensing staff interviewed staff, residents and reviewed and obtained documentation. Additional witness interviews were conducted during the investigation.

During the present visit, LPA requested additional documentation and interviewed staff members present.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20210713111719
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: SAM'S HOMECARE
FACILITY NUMBER: 306004176
VISIT DATE: 10/09/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
CONTINUED FROM FORM LIC9099-A
Resident R1 was admitted to the facility on October 3, 2020 and assessed as the time as diagnosed with multiple comorbidities such as: "dementia, [stage III] chronic kidney disease, obstructive sleep apnea, hypothyroidism, atherosclerotic aorta, atria fibrillation, hypertension, [congestive heart failure]" as well as a pacemaker implanted. R1's condition is well documented in both their physician report and individual needs assessment established upon admission. Per an incident report submitted on May 4, 2021, R1 was admitted to the hospital after sustaining a low oxygen saturation episode in spite of being provided oxygen as prescribed.

Regarding the allegation that Staff did not seek medical attention to resident in a timely manner, the following has been concluded: Based on staff interviews and incident reports submitted in May and July 2021, staff were trained to regularly check R1's oxygen saturation levels and reacted accordingly if concerning vitals were measured. As R1 sustained a health emergency on July 3, 2021, paramedics were called by a family member who was visiting at the time. There is however insufficient information corroborating that staff would have been untimely in requesting medical assistance if that had not been the case.

As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation 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: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20210713111719
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: SAM'S HOMECARE
FACILITY NUMBER: 306004176
VISIT DATE: 10/09/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
CONTINUED FROM FORM LIC9099
Resident R1 was admitted to the facility on October 3, 2020 and assessed at the time as diagnosed with multiple comorbidities such as: "dementia, [stage III] chronic kidney disease, obstructive sleep apnea, hypothyroidism, atherosclerotic aorta, atria fibrillation, hypertension, [congestive heart failure]" as well as a pacemaker implanted. R1's condition is well documented in both their physician report and individual needs assessment established upon admission. Per an incident report submitted on May 4, 2021, R1 was admitted to the hospital after sustaining a low oxygen saturation episode in spite of being provided oxygen as prescribed. Upon readmission after being discharged from a skilled nursing facility, R1 was reassessed on May 26, 2021. A written statement by R1's responsible party and attorney-in-fact confirms that R1's condition at the time of their passing was consistent with the documented condition on file as well as with earlier communication with facility staff via text, telephone and/or verbal exchanges.

As a result, the allegation that Staff did not notify authorized representative about change of resident health condition is determined to be Unfounded, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report and the list of Confidential names LIC811 were provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4