306005322-1-21-2026-22-AS-APAO-DQSVU7-20260129154412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005322
Report Date: 01/21/2026
Date Signed: 01/21/2026 04:40:01 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
08/30/2022 and conducted by Evaluator Brandon Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220830093135

FACILITY NAME:	ACTIVCARE AT YORBA LINDA		FACILITY NUMBER:	306005322
ADMINISTRATOR:	ELVA LEDESMA		FACILITY TYPE:	740
ADDRESS:	4725 VALLEY VIEW AVE		TELEPHONE:	(714) 577-8005
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	80	CENSUS: 47	DATE:	01/21/2026
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Executive Director Enrique Ledesma		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident suffered multiple falls while in care.
Facility forcing resident to take medications.
Facility not allowing resident access to their bedroom.
Facility administrator medication without obtaining consent from resident's responsible party.

INVESTIGATION FINDINGS:

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On January 21, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to continue the investigation into the allegations listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Enrique Ledesma was present and assisted on today's visit.

During the course of the investigation, the Department interviewed residents, interviewed staff, reviewed and obtained pertinent documents to the complaint. Regarding the allegation, resident suffered multiple falls while in the care, the following has been concluded: It was alleged that Resident #1 (R1) sustained multiple falls while in care. The Department was unable to review any records for R1 due to R1 moving out of the facility on September 19, 2022. Additionally, the facility no longer has any records for R1 on the premises. The Department conducted an interview with R1. However, R1 was unable to provide a statement regarding any falls she might have sustained while at the facility. The Department conducted four staff interviews. Four out of the four staff interviewed confirmed that R1 sustained falls while at the facility.
CONTINUED ON LIC9099-C

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

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 5

Control Number 22-AS-20220830093135

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: ACTIVCARE AT YORBA LINDA	FACILITY NUMBER: 306005322
	VISIT DATE: 01/21/2026

NARRATIVE

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Staff interviewed stated that R1 sustained some falls due to R1 attempting to transfer herself, even though she required assistance with transferring. Staff interviewed also stated that the facility put fall prevention methods in place for R1. The fall prevention methods put in place for R1 included a lowered bell, a fall mat, a tab alarm, and additional routine checks. Additionally, staff interviewed stated that R1 did not sustain any injuries from her falls at the facility. Although R1 sustained falls while at the facility, staff interviewed confirmed that fall prevention techniques were put in place to deter future falls, and prevent any serious injuries.

Regarding the allegation, facility forcing resident to take medications, the following has been concluded: It was alleged that R1 was forced to take medications. The Department conducted an interview with R1. However, R1 was unable to provide a statement regarding this allegation. The Department conducted seven resident interviews. One resident was unable to be qualified for an interview and another resident declined to be interview. However, five out of the seven residents interviewed denied the allegation and stated that they have never been forced to take any medications. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and stated that R1 was never forced to take any medications.

Regarding the allegation, facility not allowing resident access to their bedroom, the following has been concluded: It was alleged that the facility did not allow R1 access to her bedroom. The Department conducted an interview with R1. However, R1 was unable to provide a statement regarding this allegation. The Department conducted four staff interviews. One out of the four staff interviewed was unable to recall any information about this allegation. However, three out of the four staff interviewed denied the allegation. Staff interviewed stated that R1 was encouraged to be in the main activity room so that she could be observed by more staff since she had a history of falls at the facility. Staff interviewed also stated that they would assist R1 to her bedroom if she requested to go there. The Department conducted seven resident interviews. One resident was unable to be qualified for an interview and another resident declined to be interview. However, five out of the seven residents interviewed denied the allegation and stated that they are allowed to go to their bedrooms whenever they want to.

Regarding the allegation, facility administering medication without obtaining consent from resident's responsible party, the following has been concluded: It was alleged that the facility administered R1's PRN Ativan medication without obtaining consent from R1's responsible party. CONTINUED ON LIC9099-C

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
08/30/2022 and conducted by Evaluator Brandon Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220830093135

FACILITY NAME:	ACTIVCARE AT YORBA LINDA		FACILITY NUMBER:	306005322
ADMINISTRATOR:	ELVA LEDESMA		FACILITY TYPE:	740
ADDRESS:	4725 VALLEY VIEW AVE		TELEPHONE:	(714) 577-8005
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	80	CENSUS: 47	DATE:	01/21/2026
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Executive Director Enrique Ledesma		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility is not providing a menu.
Facility not providing a variety of meals to resident.

INVESTIGATION FINDINGS:

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On January 21, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to continue the investigation into the allegations listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Enrique Ledesma was present and assisted on today's visit.

During the course of the investigation, the Department interviewed residents, interviewed staff, reviewed and obtained pertinent documents to the complaint. Regarding the allegation, facility is not providing a menu, the following has been concluded: The Department conducted seven resident interviews. One resident was unable to be qualified for an interview and another resident declined to be interview. However, five out of the seven residents interviewed denied the allegation and stated that they are provided menus each day. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and stated that menus are posted on a daily basis. During a tour of the facility, the Department observed a daily menu posted in the dining hall. CONTINUED ON LIC9099-C

Unfounded

Estimated Days of Completion: 90

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20220830093135

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: ACTIVCARE AT YORBA LINDA	FACILITY NUMBER: 306005322
	VISIT DATE: 01/21/2026

NARRATIVE

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Regarding the allegation, facility not providing a variety of meals to resident, the following has been concluded: The Department conducted seven resident interviews. One resident was unable to be qualified for an interview and another resident declined to be interview. However, five out of the seven residents interviewed denied the allegation. Residents interviewed stated that they are satisfied with the food provided by the facility. Residents interviewed also confirmed the facility provides alternative food options if they do not like the meals that are served on that day. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and confirmed the facility provides alternative food options if residents are not satisfied with the meals that are served on that day. The Department inspected the food menu provided to residents and observed the facility provides a variety of food options to residents. The Department also observed that residents are able to order off of the alternative menu if they are not satisfied with the food options served on that day.

Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the two allegations are false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Executive Director Enrique Ledesma and a copy of the report was provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20220830093135

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: ACTIVCARE AT YORBA LINDA	FACILITY NUMBER: 306005322
	VISIT DATE: 01/21/2026

NARRATIVE

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The Department conducted an interview with R1. However, R1 was unable to provide a statement regarding this allegation. The Department conducted four staff interviews. One out of the four staff interviewed was recall any information about this allegation. However, three out of the four staff interviewed denied the allegation. Staff interviewed stated that consent was received from R1's responsible party regarding R1's PRN Ativan medication. The Department was unable to review any medication administration records for R1 due to R1 moving out of the facility on September 19, 2022. Additionally, the facility no longer has any records for R1 on the premises.

Due to the conflicting information received during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the four allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Enrique Ledesma and a copy of the report was provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC9099 (FAS) - (06/04)

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