306004839-12-12-2025-22-AS-APAO-DPHVEA-20251219152200

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004839
Report Date: 12/12/2025
Date Signed: 12/12/2025 03:59:42 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
07/11/2023 and conducted by Evaluator Fred Arias

COMPLAINT CONTROL NUMBER: 22-AS-20230711165849

FACILITY NAME:	FULLERTON VILLA		FACILITY NUMBER:	306004839
ADMINISTRATOR:	DARLENE LINDLEY		FACILITY TYPE:	740
ADDRESS:	2441 W. ORANGETHORPE AVE.		TELEPHONE:	(714) 992-5380
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	197	CENSUS:	DATE:	12/12/2025
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Jae Wan Rim		TIME COMPLETED:	04:14 PM

ALLEGATION(S):

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Lack of care and supervision resulted in resident's decline.
Facility did not notify responsible party of resident's change in condition.
Facility denied the resident's right to reject medical care or other services.
Facility did not ensure resident was provided 3 meals a day.
Facility failed to provide basic hygiene items for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. An initial investigation visit was conducted on July 11, 2023 by the Department.

It was alleged staff lack of care and supervision resulted in resident’s decline, facility did not notify responsible party of resident’s change in condition, facility denied the resident’s right to reject medical care or other services, facility did not ensure resident was provided 3 meals a day, and facility failed to provide basic hygiene items for resident. During the investigation, the Department conducted interviews with residents in care and staff. LPA Arias reviewed records obtained.

The investigation determined as follows: Regarding the allegation lack of care and supervision resulted in resident’s decline, it was reported resident 1 (R1)’s ability to express themselves verbally deteriorated as a result of neglect.
Continued on LIC9099-C dated 12/12/2025

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025

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-20230711165849

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 VILLA	FACILITY NUMBER: 306004839
	VISIT DATE: 12/12/2025

NARRATIVE

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Record review revealed R1 was admitted to the facility on June 22, 2022. On June 23, 2022, R1 was admitted to hospice care due to a terminal diagnosis of cerebral infarction. Secondary diagnoses included dementia. Visits by a hospice nurse were conducted on June 23, 2022, June 28, 2022, and July 5, 2022. On July 5, 2022, R1’s family revoked hospice services and discharged R1 from the facility. LPA interviews with seven out of seven residents state their needs are being met by staff including meals, medication management, incontinence care, and general housekeeping. LPA interviews with four out of four staff stated they assist residents with activities of daily living including showers, assistance with transfers, escorting residents to the dining area, feeding, and incontinence care.

Regarding the allegation facility did not notify responsible party of resident’s change in condition, it was reported R1 lost 14 pounds during R1’s stay at the facility from June 22, 2022 to July 5, 2022 and the responsible party was not informed. Record review revealed R1 was placed in a skilled nursing facility (SNF) from April 1, 2022 through June 22, 2022 due to a diagnosis of cerebral infarction. The SNF documented R1’s weight record on April 2, 2022 at 94lbs, April 4, 2022 at 93lbs, April 12, 2022 at 93lbs, April 17, 2022 at 92lbs, May 7, 2022 at 91lbs, May 23, 2022 at 91lbs, May 29, 2022 at 89lbs, June 5,2022 at 89lbs, June 8, 2022 at 89lbs, and June 12, 2022 at 87lbs. SNF assessments for R1 completed on April 1, 2022, April 8, 2022, April 15, 2022 and April 22, 2022 state “Rarely eats a complete meal and generally eats only about ½ of any food offered.” Hospital records for R1’s admission on July 6, 2022 document R1’s estimated weight at 80lbs. On July 8, 2022, actual weight was documented at 85lbs 15.7oz. R1’s hospital records from July 6, 2022 to July 10, 2022 indicated 25% to 71% of their meals were consumed. R1 was placed on a mechanical soft diet during the hospital stay.

Regarding the allegation the facility denied the resident's right to reject medical care or other services, it was reported the facility had R1’s family sign documents to place R1 into hospice care without understanding the purpose of hospice care. Record review revealed R1’s responsible party signed documents agreeing to place R1 into hospice care on June 23, 2022 with the hospice agency. Included in the signed documents is a patient acknowledgement form outlining the overall purpose of hospice care. R1 was in hospice care from June 23, 2022 to July 5, 2022. R1’s responsible party signed a document revoking hospice care on July 5, 2022.

Continued on LIC9099-C dated 12/12/2025

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20230711165849

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 VILLA	FACILITY NUMBER: 306004839
	VISIT DATE: 12/12/2025

NARRATIVE

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Regarding the allegation facility did not provide resident 3 meals a day, it was reported that R1 was fed porridge and was not being fed enough. LPA interviews with seven out of seven residents stated their needs are being met by the staff and get three meals per day. One out of seven residents added they need help with feeding and a staff member helps them with that. LPA interviews with two out of four staff stated part of their responsibilities is to feed residents who cannot feed themselves. One out of the remaining two staff stated they help bring food to residents’ rooms as needed. The remaining staff stated if they notice a resident not eating or eating enough, they will report it to the on-duty nurse. Record review revealed R1’s physician’s report dated June 23, 2022 stated that R1 be placed on a pureed diet.

Regarding the allegation facility failed to provide basic hygiene items for resident, it was reported R1 did not have a toothbrush. LPA interviews with three out of four staff stated they assist residents in brushing their teeth. The remaining staff did not add anything relevant to this allegation. LPA observed signage in multiple rooms indicating which residents required assistance with brushing teeth. LPA observed cups with toothbrushes openly visible in some of the residents’ rooms. LPA along with Administrator (AD) Jae Wan Rim observed the storage room full of hygiene products for resident use including toothbrushes, toothpaste, and shampoo. AD stated every resident gets a toothbrush, toothpaste, and shampoo when they move in and will provide additional supplies when needed.

Based on interviews, observations, and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

An exit interview was conducted and a copy of the report was left with the facility representative.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025

LIC9099 (FAS) - (06/04)

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