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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005385
Report Date: 09/25/2025
Date Signed: 09/25/2025 10:25:00 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
08/26/2025 and conducted by Evaluator Samer Haddadin
COMPLAINT CONTROL NUMBER: 22-AS-20250826132344
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:
09/25/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Johnny BugeongTIME COMPLETED:
10:36 AM
ALLEGATION(S):
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Facility mismanaged resident's medication
INVESTIGATION FINDINGS:
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On September 25, 2025, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to investigate the above allegation. Upon arrival, LPA Haddadin was greeted and granted entry by Johnny Bugeong. The investigation included staff and resident interviews, a review of facility records, and direct observations of the physical plant.LPA reviewed Resident 1’s (R1) medication records. Documentation reflected that R1’s medications were managed by the facility; however, insulin injections were to be self-administered by R1 with staff oversight only. On August 21, 2025, R1’s responsible party provided written instructions in preparation for scheduled lab work, directing that only Lantus insulin was to be administered, and Apidra insulin withheld. LPA verified these instructions through text message correspondence between the responsible party and the facility. {***CONTINUE 9099C***}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
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-20250826132344
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: ORANGE COUNTY CARE HOME II
FACILITY NUMBER: 306005385
VISIT DATE: 09/25/2025
NARRATIVE
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 Despite this, records and interviews confirmed that staff permitted R1 to self-administer both medications.LPA interviewed two staff members, both of whom corroborated the allegation, including one who witnessed R1 self-administering both insulins. LPA also interviewed three residents. Due to cognitive limitations, residents were unable to provide relevant information regarding the allegation.Based on record review and staff interviews, the allegation that the facility mismanaged R1’s medication was substantiated. The preponderance of evidence standard has been met. One deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6. A copy of this report and appeal rights were provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250826132344
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: ORANGE COUNTY CARE HOME II
FACILITY NUMBER: 306005385
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2025
Section Cited
CCR
87465(a)(4)
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87465(a)(4) – Incidental Medical and Dental CareFacility staff shall assist residents with self-administration of prescription medications as needed ... shall be given in accordance with the physician’s instructions.
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Administrator shall retrain all staff on medication administration requirements, emphasizing that medications must be administered strictly according to physician instructions.
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Based on interviews and records review, the facility failed to follow physician instructions for (R1)despite clear instructions to administer only Lantus prior to R1's fasting laboratory appointment. This posed an immediate health and safety risk to resident in care.
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Administrator shall also implement procedures for staff to double-verify physician orders prior to administering insulin. Documentation of training and verification procedures shall be submitted to by POC due date
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3