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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005385
Report Date: 07/11/2025
Date Signed: 07/11/2025 01:52:57 PM

Substantiated


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
04/02/2025 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250402163711
FACILITY NAME:ORANGE COUNTY CARE HOME IIFACILITY NUMBER:
306005385
ADMINISTRATOR:RASSOULI ZADEHEI, FAHIMEHFACILITY TYPE:
740
ADDRESS:27561 ALMENDRA DRIVETELEPHONE:
(949) 322-1078
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
07/11/2025
UNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Faith RassouliTIME COMPLETED:
01:51 PM
ALLEGATION(S):
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Facility does not have the required posters for public display.
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Faith Rassouli and explained the reason for today’s inspection.
The investigation into the allegation that facility does not have the required posters for public display revealed the following: During the course of the investigation, LPA inspected the facility and obtained and reviewed copies of the resident roster and staff roster.
It was alleged that the facility does not have the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) displayed in the facility as required. LPA inspected the facility and observed the facility does have a PUB 475 posted. However, LPA observed that the PUB 475 is posted in the kitchen, instead of the main entryway of the facility as required, and LPA measured the PUB 475 to be approximately 17 inches by 22 inches, instead of 20 inches by 26 inches as required. The information obtained corroborated the allegation.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
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 5
Control Number 22-AS-20250402163711
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: ORANGE COUNTY CARE HOME II
FACILITY NUMBER: 306005385
VISIT DATE: 07/11/2025
NARRATIVE
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During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20250402163711
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: ORANGE COUNTY CARE HOME II
FACILITY NUMBER: 306005385
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2025
Section Cited
CCR
87468(c)(2)(A)
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87468 Personal Rights… (c) Licensees shall prominently post (2) … (A) … the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) … 20" x 26" in size and be posted in the main entryway of the facility…
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The licensee has already posted a proper sized PUB 475 in the main entryway of the facility and LPA confirmed. POC CLEARED.
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Based on observation, the licensee did not ensure the PUB 475 was the correct size and in the entryway of the facility, which poses a potential 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: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/02/2025 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250402163711

FACILITY NAME:ORANGE COUNTY CARE HOME IIFACILITY NUMBER:
306005385
ADMINISTRATOR:RASSOULI ZADEHEI, FAHIMEHFACILITY TYPE:
740
ADDRESS:27561 ALMENDRA DRIVETELEPHONE:
(949) 322-1078
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
07/11/2025
UNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Faith RassouliTIME COMPLETED:
01:51 PM
ALLEGATION(S):
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Facility not giving medication to resident as prescribed.
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Faith Rassouli and explained the reason for today’s inspection.

The investigation into the allegation that facility not giving medication to resident as prescribed revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Medication List, and staff training records.

CONTINUED
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20250402163711
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: ORANGE COUNTY CARE HOME II
FACILITY NUMBER: 306005385
VISIT DATE: 07/11/2025
NARRATIVE
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It was alleged that R1’s prescription for Atorvastatin changed from 20MG to 10MG, the facility received both doses from the pharmacy in February 2025, the facility gave R1 both doses for multiple days despite the 20MG dose being discontinued, and in March 2025 the bubble packs for all of R1’s medications showed that R1 had missed multiple days of their medications. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA inspected the medications for all six residents did not observe any current medication errors. LPA reviewed R1’s Medication List and did not obtain information regarding the allegation. LPA interviewed AD who denied giving R1 both doses of Atorvastatin at the same time, stating that the 20MG dose was discontinued when the 10MG dose was received, and denied that R1 missed doses of their medications. One witness stated they observed staff trying to give R1 both doses of the Atorvastatin and prevented them from doing so. R1 stated that they recall receiving two doses of the Atorvastatin, but could not recall for how many days. However, AD and two staff denied that this occurred, instead claiming that when the new dose was received the old one was put to the side and replaced by the new dose. AD and two staff also stated that residents receive all their medications as prescribed. LPA reviewed staff training records which showed four out of four staff have up-to-date medication training. LPA interviewed the five other residents and did not obtain information corroborating any other issues with medications. No information was obtained indicating that R1 suffered any effects from the alleged medication error and interviews with AD and a witness revealed that R1’s Atorvastatin prescription has since been increased to 40MG, which is higher than both previous doses combined. The information obtained is conflicting.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5