306005479-2-18-2026-22-AS-APAO-DRW7A9-20260305202909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005479
Report Date: 02/18/2026
Date Signed: 02/18/2026 04:50:04 PM

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
12/23/2025 and conducted by Evaluator Jenifer Tirre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20251223142340

FACILITY NAME:	ROSSMOOR SUNSHINE VILLA-OAK WAY		FACILITY NUMBER:	306005479
ADMINISTRATOR:	JULIO NAVALLO		FACILITY TYPE:	740
ADDRESS:	12772 OAK WAY DRIVE		TELEPHONE:	(562) 572-9931
CITY:	ROSSMOOR	STATE: CA	ZIP CODE:	90720
CAPACITY:	6	CENSUS: 5	DATE:	02/18/2026
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Licensee Ricardo Banos		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Due to lack of care and supervision resulted in resident eloping

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to initiate complaint investigation. LPA Tirre was greeted and granted entry into the facility by staff and explained reason for visit.
During the course of investigation, LPA reviewed records, conducted interviews, toured facility and made visual observations. Department requested pertinent documentation such as Physician’s Report, Resident Apprasial,Incident Report, Personnel report and Resident Roster. The investigation conducted revealed the following:
On December 23, 2025 the department received a complaint alleging due to lack of care and supervision resulted in resident eloping. Record review revealed that Resident 1 (R1) has a Dementia diagnosis listed on Physician’s report dated 10/19/2025. R1’s Physician’s report also notates under capacity for self care, R1 is not able to leave the facility unsupervised. Under Behavioral Expressions section of Physician’s report R1 is noted to have disorientation, Lack of hazard awareness, unsafe wandering and elopement as behaviors
CONTINUED ON 9099C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026

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-20251223142340

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: ROSSMOOR SUNSHINE VILLA-OAK WAY	FACILITY NUMBER: 306005479
	VISIT DATE: 02/18/2026

NARRATIVE

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Residents appraisal dated 10/26/2025 notes under Services needed, R1 needs special observation and night supervision due to confusion, forgetfulness & wandering. Record Review revealed Department received Unusual Incident Report from facility on 12/23/2025, notifying Department of R1’s exiting the facility without staff’s awareness. Incident report indicates that staff 1 & 2 were present in the facility and both helping assist another resident (R2) during the time incident occurred. Incident report stated that R1 had a history of sundowning and no previous incidents of exiting facility without supervision.

Interviews with staff stated that staff searched facility and surrounding neighborhood for R1. Staff interviews stated that Licensee’s who were out of town during the time of incident and were contacted regarding R1. Staff Interviews stated that incident occurred around 4:30PM. Staff interviews revealed that Staff contacted family and local police regarding R1. Staff interviews also revealed that R1 had a 1:1 care plan for R1 between the hours of 5:00-10:00pm due to R1’s sundowning behavior. Five of Five staff stated R1 had no previous incidents of eloping from facility. Interviews with 3 of 5 staff state R1 was located by Police and taken to Local Hospital around 9:00PM.

Interview with witness states R1 was missing approximately for four hours. Witness interview stated that Staff left R1 unsupervised knowing Their condition. Witness interview stated Facility had alarm for front door upon opening.

During Department visit, LPA observed that each exits in and surrounding facility had audible alarms that chime each time someone exits the doors. Interview with staff 1 and staff 2 stated they did not hear alarm go off while they assisted R2 due to R2 was verbally loud during transfer to bed. LPA observed cameras in common areas and perimeter of home which Staff stated Licensee has access to.

Per information gathered from Investigation, the preponderance of evidence has been met, deeming the allegation “Due to lack of care and supervision resulted in resident eloping” to be Substantiated.

The facility is being cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted with Representative and copy of report was discussed, provided along with appeal rights.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20251223142340

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: ROSSMOOR SUNSHINE VILLA-OAK WAY	FACILITY NUMBER: 306005479
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/18/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/23/2026 Section Cited CCR 87705(e)(5)	1 2 3 4 5 6 7	Care Of Persons With Dementia 87705(e)(5) Facility staff shall ensure the continued safety of residents if they wander away from the facility... This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to train all staff on elopement prevention training and to provide proof of training to LPA by the POC due date 2/23/2026
	8 9 10 11 12 13 14	Resident 1 left the facility unattended on December 21, 2025 for approximately four hours which poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 02/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026

LIC9099 (FAS) - (06/04)

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