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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005477
Report Date: 06/16/2025
Date Signed: 06/16/2025 10:57:10 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
09/15/2023 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230915143404
FACILITY NAME:JC HOME FOR SENIORS-CAREFACILITY NUMBER:
306005477
ADMINISTRATOR:PARUNGAO, MARIA EFACILITY TYPE:
740
ADDRESS:15332 SHASTA LANETELEPHONE:
(714) 622-5118
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 6DATE:
06/16/2025
UNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Administrators Cherry Paranguo and Jay ParanguoTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Lack of care and supervision resulted in resident's fall and injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Jenifer Tirre, met with Administrators Cherry and Jay Paranguo for the purpose of delivering findings for the above allegations. The investigation consisted of medical records obtained, interviews conducted, and observations made. On September 15, 2023, the department received allegations that Lack of care and supervision resulted in resident’s fall. The investigation was completed by the department and revealed the following:

On September 8, 2023, Resident 1 (R1) had an unwitnessed fall inside their bedroom after kicking the bed away from the wall. R1 rolled off bed, fell on floor between bed and wall. R1 sustained injuries to left shoulder and elbow. R1’s Physician’s Report dated June 29, 2023, notes R1 is non ambulatory, unable to transfer from bed without assistance and has foley catheter. R1 requires full assistance for transfers and toileting including frequent checks of catheter and emptying bag. R1 was transported to Orange County (OC) Huntington Beach Hospital on September 8, 2023, and hospital records dated September 8, 2023, revealed that R1’s main complaint was back pain. CONTINUED ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
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 4
Control Number 22-AS-20230915143404
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: JC HOME FOR SENIORS-CARE
FACILITY NUMBER: 306005477
VISIT DATE: 06/16/2025
NARRATIVE
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R1’s attending physician ordered lab work for R1’s lumbar area. Hospital records dated September 8, 2023, revealed lab results showed R1 had a diagnosis of Diffuse Osseus Demineralization which according to Mayo Clinic is a process that causes mineral loss in bones making them more prone to fracture and moderate to severe stenosis, which is pain in the spine. Per Orange County Huntington Beach Hospital X-ray records dated September 8, 2023, shows no bone fractures and no joint dislocation. Attending physician reported no significant tenderness over both regions, leading physician to believe these were old fractures. R1’s evaluation was consistent with soft tissue injury and consistent with bony injury. R1’s left hand and shoulder were cleaned. Hospital discharge papers dated September 8, 2023, indicated R1 was discharged back to facility same day.

Three of four staff interviewed stated that it is possible that the wheels on R1’s bed may have not been locked. Four of four staff confirmed that staff use left side of R1’s bed to assist with Activities of Daily Living (ADL’s) and during assistance the front wheels are taken off lock for staff members to have better access to R1. Interviews revealed that all four of four staff members confirmed that R1’s bed was pushed away from wall. Three of four staff interviews revealed that R1 is a restless sleeper. Interview with R1 confirms that staff forgot to lock the wheel of bed causing R1 to roll out of bed.

It was observed that when wheels were locked, bed was hard to move out of place. However, if only one front wheel was unlocked, R1’s bed moved with ease in this position.

Based upon Medical Records, interviews, and observations the allegation that Lack of care and supervision resulted in resident’s fall and soft tissue injury revealed that the preponderance of evidence has been met and was found to be SUBSTANTIATED.

See LIC9099-D for cited deficiencies and immediate civil penalty as per Title 22 Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49.



An exit interview was conducted with Cherry and Jay Paranguo. A copy of this report, along with LIC9099-D, Appeal Rights, Civil Penalty Assessment-LIC 421 IM and the LIC 811, identifying confidential names were provided and explained.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20230915143404
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: JC HOME FOR SENIORS-CARE
FACILITY NUMBER: 306005477
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2025
Section Cited
CCR
87464(f)(1)
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Basic Services shall at a minimum include care and supervision as defined in section 87101(c)(3) and Health and safety code section 1569.2(c) Requirement was not met as evidenced by:
interviews & observations made, confirmed resident's whhels to bed were left unlocked
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Licensee to provide in service training to staff on fall preventions. Licensee to provide anti sliding furniture stopper for bed wheels. Licensee to provide proof by POC Close of Business due date 06/17/25.
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by staff causing bed to easily move in position resulting in resident rolling onto floor. This poses an immediate risk to resident's health and safety.
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
09/15/2023 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230915143404

FACILITY NAME:JC HOME FOR SENIORS-CAREFACILITY NUMBER:
306005477
ADMINISTRATOR:PARUNGAO, MARIA EFACILITY TYPE:
740
ADDRESS:15332 SHASTA LANETELEPHONE:
(714) 622-5118
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 6DATE:
06/16/2025
UNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Administrator Cherry ParungaoTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility licensee is unavailable to resident's responsible party
INVESTIGATION FINDINGS:
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Department investigated the allegation Facility Licensee is unavailable to resident’s responsible party. Interviews conducted with facility residents and responsible parties, confirms that four of four responsible parties state they do not have issues reaching Administrator/Licensee. Interviews confirmed responsible parties are being contacted by Administrator/Licensee regarding residents’ medical appointments, as well as if responsible parties are leaving messages, the Licensee responds in a timely manner and gives updates on residents’ health conditions. All Responsible parties confirmed they do not have issues with staff and stated they like the care being provided to their loved ones. R1’s responsible party confirmed Licensee is available and responsive to them.
This agency has investigated the complaint alleging facility Licensee is unavailable to resident’s responsible party. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/ or is without reasonable basis.

An exit interview was conducted with Administrator Paranguo , and a copy of this report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
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 4