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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004454
Report Date: 10/20/2025
Date Signed: 10/24/2025 08:13:49 AM

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
10/16/2025 and conducted by Evaluator Eboni Bentley
COMPLAINT CONTROL NUMBER: 22-AS-20251016145831
FACILITY NAME:NS CAREFACILITY NUMBER:
306004454
ADMINISTRATOR:NOVAC SOFRONIFACILITY TYPE:
740
ADDRESS:10431 AVENIDA CINCO DE MAYOTELEPHONE:
(714) 599-3531
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
10/20/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Novac Sofroni -Licensee/AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility failed to assist resident with follow up medical appointments.
INVESTIGATION FINDINGS:
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On October 20, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted a 10-day complaint visit to investigate the above allegation. LPA met with Caregiver Astrid Jocelyn Zamarripasalman, stated the purpose of the visit, and was granted entry into the facility. Licensee Novac Sofroni was contacted by telephone, arrived a short time later, and remained throughout the visit to assist with the investigation. LPA stated the purpose of the visit to Licensee Novac Sofroni and conducted an interview.

During today’s visit, LPA observed five residents present and two caregivers on duty. LPA conducted a tour of the facility with Licensee and observed no imminent health and safety issues. LPA reviewed documents for five residents and two staff including the following facility records: Resident/Staff Rosters, Personnel Record (LIC500), face sheets, physician’s reports, and needs and services appraisals.

Report continued on LIC 9099C….
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
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-20251016145831
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: NS CARE
FACILITY NUMBER: 306004454
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2025
Section Cited
CCR
87465(a)(1)
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87465(a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not met as evidenced by:
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The Licensee stated they will ensure appointments are schduled for R1 by the facility, and submit proof to CCLD via email by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above. LPA reviewed R1’s record that medical appointments for labratory and OBGYN were not scheduled by facility. This poses a potential health, safety, and personal rights 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: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20251016145831
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: NS CARE
FACILITY NUMBER: 306004454
VISIT DATE: 10/20/2025
NARRATIVE
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Regarding allegation: Facility failed to assist resident with follow up medical appointments. It was alleged that the facility failed to assist resident with follow up medical appointments for laboratory (labs), Obstetrics and Gynecology (OB/GYN), and Psychiatry.

LPA interviewed five residents and two staff. LPA is unable to qualify two resident interviews due to their medical condition. Per Licensee, Resident 1 (R1) schedules their own appointments and has the house phone all day which they use to schedule the appointments on their own. Licensee stated R1 has missed some appointments but they are not sure which ones.

Based on record review of Progress Notes, on September 5, 2025 Community Care Center conducted an in-office exam with R1 and provided referrals for follow-up appointments for labs, OB/GYN, and Psychiatry. R1 was seen at Community Care Center again on October 15, 2025 and based on appointment records dated October 20, 2025, R1 did not attend appointments for labs and OB/GYN by that date.

Based on LPA interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed to be SUBSTANTIATED. A deficiency is being cited as per California Code of Regulations, Title 22, Division 6 and Chapter 8.

An exit interview was conducted with Licensee Novac Sofroni, and a copy of this report including the LIC811, LIC9099D, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3