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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005478
Report Date: 03/18/2026
Date Signed: 03/18/2026 12:00:24 PM

Unfounded


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
10/28/2024 and conducted by Evaluator Hanna Gough
COMPLAINT CONTROL NUMBER: 22-AS-20241028152659
FACILITY NAME:SAINT BENEDICT CARE LLCFACILITY NUMBER:
306005478
ADMINISTRATOR:ALMIRANEZ, ULDARICOFACILITY TYPE:
740
ADDRESS:8925 CANARY AVENUETELEPHONE:
(949) 290-6006
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
03/18/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Uldarico AlmiranezTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility is not adhering to resident's dietary needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility for the purpose of investigating the above mentioned complaint allegation. LPA was greeted and granted entry into the facility by staff. LPA met with Administrator (AD) Uldarico Almiranez and discussed the purpose of the visit.

The investigation into the allegation facility is not adhering to resident's dietary needs revealed the following: Resident 1 (R1) moved into the facility on September 28, 2018. LPA reviewed records and observed a physician’s report for R1 dated April 4th, 2024, that stated that R1 has no special diet orders. It was also noted on R1s physician’s report that they were unable to feed themselves and were unable to communicate their needs. LPA reviewed R1’s needs and service plan dated January 08, 2022, which notates a need for staff to assist R1 with full Activities of Daily Living (ADLs).

Continue on LIC9099C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
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-20241028152659
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: SAINT BENEDICT CARE LLC
FACILITY NUMBER: 306005478
VISIT DATE: 03/18/2026
NARRATIVE
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On October 26, 2024, R1 was hospitalized due to difficulty breathing. Per interview with R1’s Responsible Party, Responsible Party was unaware of any special diet R1 may have been on. R1’s responsible party stated that R1 was still eating and swallowing towards the end of their time at the facility and had no concerns with aspiration.

During the course of the investigation the Department conducted interviews. During interviews with AD & Staff #1 (S1), it was revealed that R1 had no dietary restrictions that either were aware of. S1 informed LPA that R1 was able to eat all the food that was provided just fine with staff assistance.

LPA was unable to interview R1 at the time of the investigation.

Based on observation, interviews, records reviewed, and information gathered during the investigation the preponderance of evidence standard has not been met, therefore the above allegation is deemed UNFOUNDED. Meaning the allegation facility is not adhering to resident’s dietary needs was false, could not have happened and/or is without a reasonable basis. The Department therefore dismissed the complaint.

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

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
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
10/28/2024 and conducted by Evaluator Hanna Gough
COMPLAINT CONTROL NUMBER: 22-AS-20241028152659

FACILITY NAME:SAINT BENEDICT CARE LLCFACILITY NUMBER:
306005478
ADMINISTRATOR:ALMIRANEZ, ULDARICOFACILITY TYPE:
740
ADDRESS:8925 CANARY AVENUETELEPHONE:
(949) 290-6006
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
03/18/2026
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Uldarico AlmiranezTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained a pressure injury while in facility care due to neglect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility for the purpose of investigating the above mentioned complaint allegation. LPA was greeted and granted entry into the facility by staff. LPA met with Administrator (AD) Uldarico Almiranez and discussed the purpose of the visit.

The investigation into the allegation resident sustained a pressure injury while in facility care due to neglect revealed the following: LPA reviewed Resident #1 (R1) physicians report dated April 04, 2024, that stated R1 had a history of skin condition or breakdown. R1 was not able to communicate their needs and was bedridden per their physician’s report. Per records reviewed, R1’s needs and services plan dated January 8, 2022, states that R1 had fragile skin and that facility staff will help R1 with all ADLs.

Continue on LIC 9099C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
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-20241028152659
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: SAINT BENEDICT CARE LLC
FACILITY NUMBER: 306005478
VISIT DATE: 03/18/2026
NARRATIVE
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The Department reviewed Hospital medical records for R1 dated October 26, 2024, through November 2, 2024. The records revealed the following: Upon admission, R1 was diagnosed with sepsis, pneumonia, bacteremia and a urinary tract infection. A pressure injury was found on R1’s coccyx and was diagnosed to be a stage 4 pressure wound that required daily wound care and dressing changes with repositioning every 2 hours. Per hospital staff notations, the family was aware of the pressure injury prior to hospitalization of R1 and reported that a physician assistant was coming to treat the wound.

During the Department’s interview with R1’s Responsible Party it was revealed that they knew about a wound and felt it was due to the resident being bedridden. Interviews with staff #1 (S1) revealed that they would help treat and dress R1’s pressure injury themselves. No skilled professional was found to be treating R1’s pressure injury while in care at the facility. During interviews with the staff #2 (S2) it was revealed that R1 was on hospice when R1 first arrived at the facility but was discharged and had not been readmitted. Hospice discharge summary dated July 29, 2019, did not indicate R1 had any pressure injuries at the time of discharge. A review of facility records revealed no documentation of R1’s wound or pressure injury prevention measures for R1 such as notations of repositioning, incontinence care and skin integratory reports.

Hospital discharge summary notes that R1 was transitioned to inpatient hospice care on October 30, 2024. On October 31, 2024, wound culture results revealed that there was a presence of bacterial growth in the pressure wound. R1 later passed away at the hospital on November 2, 2024.

Based on interviews conducted, record review and information gathered during the investigation, the facility failed to address resident’s care needs resulting in an untreated pressure injury. Therefore, the preponderance of evidence standard has been met, the allegation Resident sustained a pressure injury while in facility care due to neglect is found to be SUBSTANTIATED.

California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC9099D.

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(e).

An exit interview was conducted and a copy of this report, LIC9099-D, confidential names list and appeal rights were left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20241028152659
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: SAINT BENEDICT CARE LLC
FACILITY NUMBER: 306005478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2026
Section Cited
CCR
87464(f)(1)
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Basic Services 87464(f)(1)
Basic services shall at a minimum include: Care and supervision defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement was not met as evidence by:
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Licensee stated they will conduct an In service on how to identify a stage 1 and 2 pressure injury, when to send resident out for higher level of care due to pressure injury and how to care for a stage 1 and 2 pressure injury with staff and send proof to LPA by POC due date.
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The Department reviewed medical records for R1 that states that R1 had a stage 4 pressure injury upon admission to the hospital that facility staff was caring for. This poses an immediate health, safety and personal rights risk to residents 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: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5