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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005565
Report Date: 05/13/2025
Date Signed: 05/13/2025 03:04:20 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
02/16/2024 and conducted by Evaluator Cassandra Mikkelson
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240216162152
FACILITY NAME:AK AND DAVID SENIOR CAREFACILITY NUMBER:
306005565
ADMINISTRATOR:CATACUTAN, MARY JEANFACILITY TYPE:
740
ADDRESS:24302 BARK STTELEPHONE:
(949) 677-3394
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Mary Jean Catacutan, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident sustained a fracture due to lack of care from staff
Staff spoke inappropriately to resident
Staff did not ensure that resident was adequately fed
Staff threw objects at resident
Staff handled resident in a rough manner
Staff did not seek medical attention for resident in a timely manner
Staff interfered with resident visits
Staff video recorded resident without consent
INVESTIGATION FINDINGS:
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On May 13, 2025, Licensing Program Analyst (LPA) Cassandra Mikkelson contacted the Administrator via phone to deliver final findings regarding a complaint that was received on 02/16//2024. LPA Mikkelson spoke with ***, Administrator, and explained the purpose of the call. During the investigation, the Department conducted multiple interviews and reviewed extensive documentation.

The results of the investigation are as follows:

**Continued on 9099-C page**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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-20240216162152
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: AK AND DAVID SENIOR CARE
FACILITY NUMBER: 306005565
VISIT DATE: 05/13/2025
NARRATIVE
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Resident sustained a fracture due to lack of care from staff

Interviews conducted and records reviewed indicated that Resident R1 did not sustain any fractures or head injuries after the fall that occurring on 02/15/2024. Interviews with staff indicated that staff were present and were able to assist R1 during fall. Hospital records indicated that R1 did not have any injuries or fractures, but a sling was requested due to bruising and pain in arm from fall. Based on records reviewed and interviews conducted, there is insufficient evidence to corroborate the allegation.

Staff spoke inappropriately to resident

Interviews conducted indicated that staff speak appropriately to residents in care. Staff do not yell or talk inappropriately to residents in care. Interviews with residents indicate that staff are kind and there are no complaints regarding staff. Based on records reviewed and interviews conducted, there is insufficient evidence to corroborate the allegation.

Staff did not ensure that resident was adequately fed

Interviews conducted indicated that residents are adequately fed at the facility. Residents are able to eat breakfast, lunch and dinner with snacks as needed. Interviews with residents in care indicated that there is plenty to eat and a good variety of foods and meals to choose from. Based on records reviewed and interviews conducted, there is insufficient evidence to corroborate the allegation.

Staff threw objects at resident

Interviews conducted indicated that staff do not throw objects at residents in care. Interviews with residents indicated that they were not aware of any objects being thrown at the facility. Based on records reviewed and interviews conducted, there is insufficient evidence to corroborate the allegation.

**Continued on 9099-C2 page**

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240216162152
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: AK AND DAVID SENIOR CARE
FACILITY NUMBER: 306005565
VISIT DATE: 05/13/2025
NARRATIVE
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Staff handled resident in a rough manner

Interviews conducted indicated that staff do not handle residents in a rough manner. Interviews with residents indicated that staff are kind. Interviews with staff indicated that staff are properly trained on handling or transferring residents. Based on records reviewed and interviews conducted, there is insufficient evidence to corroborate the allegation.

Staff did not seek medical attention for resident in a timely manner

Interviews conducted indicated that R1 went to the hospital frequently due to pain. Interviews with staff indicated that facility Administrator was the person who would take R1 to the hospital or doctors appointments. Staff called 9-1-1 at the request of R1 based on R1’s care needs or if any injuries occurred. Based on records reviewed and interviews conducted, there is insufficient evidence to corroborate the allegation.

Staff interfered with resident visits

Interviews with residents indicated that staff did not interfere with resident visits. Staff respected each resident’s wishes and would assist with visitors that came. Interviews with staff indicated that they only turned away visitors at the request of the resident themselves. Resident R1 would sometimes request to not have any visitors as it overwhelmed R1 at times. Based on records reviewed and interviews conducted, there is insufficient evidence to corroborate the allegation.

Staff video recorded resident without consent

Interviews with residents indicated that there were no cameras in resident rooms other than Resident R1. R1 had a camera in their room per their response party’s request. Interviews with staff indicated that they were aware of the camera, but it only was a video feed, no audio was allowed. Staff indicated that R1 was aware of the video camera in their room and had consented to having it there. Based on records reviewed and interviews conducted, there is insufficient evidence to corroborate the allegation.

Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3