306005464-9-17-2025-22-AS-APAO-DLSR9G-20250923124931

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005464
Report Date: 09/17/2025
Date Signed: 09/17/2025 12:54:29 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
02/07/2022 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220207091659

FACILITY NAME:	FREEDOM MANOR, THE		FACILITY NUMBER:	306005464
ADMINISTRATOR:	MACH, MYLA G		FACILITY TYPE:	740
ADDRESS:	23672 CAVANAUGH ROAD		TELEPHONE:	(562) 536-8860
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 5	DATE:	09/17/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Myla Mach		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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-Staff are not changing residents diaper timely
-Staff yell at residents in care
-Staff are not turning resident timely
-Staff cannot meet resident needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation to the above identified complaint allegations. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Myla Mach, Administrator and explained the purpose of the visit.

Findings are based upon this investigation which included tour of the facility, facility file review, resident file review and interviews conducted.

It is alleged that staff are not changing residents’ diaper timely. An interview with 3 of 3 staff stated that staff change the residents as often as needed. Staff check on the residents that wear diapers often and do various checks hourly. An interview with 6 of residents stated that staff check on them often and if

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220207091659

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: FREEDOM MANOR, THE	FACILITY NUMBER: 306005464
	VISIT DATE: 09/17/2025

NARRATIVE

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diapers need to be changed, they change it. Residents stated they don’t think they are left soiled and have no issues to report.

It is alleged that staff yell at residents in care. An interview with 6 of 6 residents stated that staff are very good to them, are patient with them and have not seen any staff yell at any residents. There are residents that are hard of hearing and sometimes staff raise their voice so residents can hear but yell no we have not seen. An interview with 3 of 3 staff stated that they have not received any complaints from residents that staff yell at them or have seen any of their coworkers’ yell at the residents.

It is alleged that staff are not turning resident timely. The interview with 3 of 3 staff stated that it is a general rule that is followed for staff to turn residents that need to be rotated every 2 hours. An interview with 6 of 6 residents stated that they have observed residents getting rotated but are unsure of the time frame or how often because they don’t look at the time.

It is alleged that staff cannot meet residents’ needs. LPA conducted a facility visit on January 15, 2022, and the census was 6 residents. An interview with 3 of 3 staff stated that generally there is 2-3 staff per shift to assist with residents. There hasn’t been an issue with being able to assist or meet the needs of the residents. Staff are very capable of meeting the needs of the residents. An interview with 6 of 6 residents stated that they get their needs met by staff all the time and don’t have an issue to report. The staff is very good at assisting them when it is needed.

Based on the information mentioned above, the Department is unable to ascertain if the allegation 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, this allegation is deemed Unsubstantiated.

An exit interview was conducted with the Administrator and a copy of this LIC9099 report was left at facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025

LIC9099 (FAS) - (06/04)

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