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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004515
Report Date: 10/14/2025
Date Signed: 10/14/2025 03:11:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/26/2025 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250826220701
FACILITY NAME:HOUSE AT VINEWOODFACILITY NUMBER:
306004515
ADMINISTRATOR:LINDA P. BOLIVARFACILITY TYPE:
740
ADDRESS:17382 VINEWOOD AVENUETELEPHONE:
(714) 486-1810
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:6CENSUS: 4DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Linda Bolivar - Licensee/Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not administer medication to a resident in care.
Staff are not following resident's dietary plan.
Staff are not properly cleaning a resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannouced visit to deliver complaint findings. LPA was greeted and granted entry into the facilty and explained the reason for the visit.

The Department received a complaint on 08/26/2025 and the initial 10 day visit was conducted on 09/02/2025. During the initial visit LPA Mendivl obtained copies of pertinent documents such as physician's reports, medication administration records and hospital discharge paperwork for Resident 1 (R1) LPA Mendivil also interviewed staff and residents. Regarding the allegations Staff did not administer medication to a resident in care, Staff are not following resident's dietary plan and Staff are not properly cleaning a resident in care the investigation revealved the following:

R1 was admitted to the facility on 07/21/2025 and based on physician's report dated 07/15/2025 R1 was diagnosed with major neurocognitive disorder and is listed to be able to communicate their own needs.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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-20250826220701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HOUSE AT VINEWOOD
FACILITY NUMBER: 306004515
VISIT DATE: 10/14/2025
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
It was alleged that staff did not administer medication as prescribed for R1 per review of Medication Administrator Record (MAR) for July and August 2025 the R1 was given medication as prescribed. Per interviews with 3 out of 3 staff they administer medications as prescribed. Interviews with 1 out of 4 residents stated they are getting their medications as prescribed, the 3 remaining residents were not oriented to place and time.

It was alleged the facility is not following the resident's dietary plan. Per review of physician's report dated 07/15/2025 there was no mention of special diet for R1 and it was not until hospital discharge paperwork dated 08/22/2025 a modified diet was mentioned. The paperwork advised "no beef/pork, lactose intolerant and take lactaid before every meal." Per review of MAR starting on 08/22/2025 lactaid was provided at each meal. Based on interviews with Licensee Linda Bolivar, R1 did not eat lunch and therefore staff did not provide lactaid at lunch time. Per interview with Licensee Linda if someone has a modified diet they follow physician's orders.

It was alleged the staff are not properly cleaning a resident in care, per interviews with 3 out of 3 staff stated that they assist residents as needed, including changing briefs or providing assistance in the bathroom. Interviews with staff stated they properly wipe residents. Per LPA Mendivil observations all residents are well groomed and dressed appropriately and the facility does not have any odors.

Therefore based on the preponderance of evidence through records reviewed and interviews the allegations Staff did not administer medication to a resident in care, Staff are not following resident's dietary plan and Staff are not properly cleaning a resident in care are determined to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of this report and LIC 811 provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2