306004379-1-23-2026-22-AS-APAO-DQT8M7-20260129213748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004379
Report Date: 01/23/2026
Date Signed: 01/23/2026 05:12:52 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
09/07/2021 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210907083444

FACILITY NAME:	MOMS AND DADS		FACILITY NUMBER:	306004379
ADMINISTRATOR:	ACE JACER EDORA TABLANG		FACILITY TYPE:	740
ADDRESS:	6177 NORSTADT WAY		TELEPHONE:	(714) 883-3140
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS: 3	DATE:	01/23/2026
		UNANNOUNCED	TIME BEGAN:	02:02 PM
MET WITH:	Reca Yap		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff not following physician's instructions.
Resident developed UTI's and sepsis while in care as a result of neglect
Resident was forced to sleep in living room.
Staff are not keeping resident's bedding sanitary.
Resident's toileting needs not being met while in care.
Staff is mishandling a resident's personal funds.
Resident's bathing needs not being met.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to investigate the complaint allegations listed above. LPA Haley explained the reason for the visit upon entry. The complaint investigation consisted of interviews and document review.

Regarding the allegation: Staff not following physician's instructions.
During the investigation, it was not exactly clear if Resident 1 (R1) was diagnosed with scabies or not. According to Staff 1 (S1) and Witness 1 (W1), R1 was not diagnosed with scabies. R1’s roommate was diagnosed with scabies. During an interview with S1, R1 became itchy and S1 reported the itchiness to R1’s home health nurse. S1 says R1’s home health nurse diagnosed R1 with a ringworm and advised the resident to be seen by their physician, and it is alleged that R1’s physician prescribed medication cream for a ring worm. It’s not clear if R1 was ever diagnosed with scabies.

Regarding the allegation: Resident developed UTI's and sepsis while in care as a result of neglect.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
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 3

Control Number 22-AS-20210907083444

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: MOMS AND DADS	FACILITY NUMBER: 306004379
	VISIT DATE: 01/23/2026

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

During an interview with S1, it was confirmed that R1 did get sent to the hospital for a UTI. However, S1 says changing the resident was not the problem. According to S1 if R1 was not being changed, R1 would have other complications like redness and bedsores if the resident was not being changed. According to S1, R1 was not drinking enough fluids, and S1 said we could not force the resident to drink more fluids, only offer.

Regarding the allegation: Resident was forced to sleep in living room.
It is unclear if R1 was ever forced to sleep on in the living room. During an interview with Witness 1 (W1), they stated, the facility moved R1 out of the room with R2 at the request of the R1's family because of R2’s scabies diagnosis. S1 and S2 denied R1 ever slept in the living room. According to S1, R1 was moved into the room of a Resident 3 (R3) who was sent to the hospital and then sent to rehab. According to S1, the facility consulted with the department and the infection control requirements regarding separating the roommates (R1 & R2) and were advised they could move a resident to a vacant room. S1 claims R1 was moved into R3's room because it was vacant while the resident was out of the facility.

Regarding the allegation: Staff are not keeping resident's bedding sanitary.
During the investigation there was no evidence provided to corroborate the complaint allegation. During interviews there was no information provided about R1’s bed being kept in unsanitary conditions. When S1 and S2 were asked about the allegation, they had no idea what the allegation was about.

Regarding the allegation: Resident's toileting needs not being met while in care.
During the investigation there was no evidence provided to corroborate the complaint allegation. S1 denied the complaint allegation. S1 claims staff changed R1 or the resident would have gotten bedsores. According to S1, R1 did not have any bedsores or redness on their skin.

Regarding the allegation: Staff is mishandling a resident's personal funds.
During the investigation there was no evidence provided to corroborate the complaint allegation. S1 and S2 denied the complaint allegation. When both of the staff members (S1 & S2) were asked about the resident stimulus check, neither staff member had a clue what was being referred to.

Continued on LIC9099C Page 2 of 3

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
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 3

Control Number 22-AS-20210907083444

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: MOMS AND DADS	FACILITY NUMBER: 306004379
	VISIT DATE: 01/23/2026

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

Regarding the allegation: Resident's bathing needs not being met.
During the investigation there was no evidence provided to corroborate the complaint allegation. According to S1, R1 was always clean. S1 says the staff offered a shower every day, and R1 usually agreed to the shower twice a week. However, S1 says the days R1 was not showered, the staff usually gave her a sponge bath and would sit R1 on the toilet and wash the resident’s private areas with soap and water up to help keep them clean.

Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed unsubstantiated.

An exit interview was conducted and a copy of this report was provided.

Page 3 of 3

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
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: 3 of 3