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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005694
Report Date: 11/19/2025
Date Signed: 11/19/2025 11:57:05 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/14/2025 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20251114133858
FACILITY NAME:DEL'S HAVENFACILITY NUMBER:
306005694
ADMINISTRATOR:MANALO, DIANNAFACILITY TYPE:
740
ADDRESS:29835 ANDREA WAYTELEPHONE:
(949) 418-3222
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 4DATE:
11/19/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Dianna Manalo and Liberty AbdonTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Facility staff mismanaged resident's controlled substance
Resident's medication records were not maintained
Resident's hospice records were not maintained
Facility staff did not provide resident's records to their responsible party
Facility staff falsified resident's records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the investigation, LPA toured the facility and interviewed staff and witness. Regarding the allegations that facility staff mismanaged resident's controlled substance, resident's medication records were not maintained, resident's hospice records were not maintained, facility staff did not provide resident's records to their responsible party and facility staff falsified resident's records, the investigation revealed the following: Resident 1 (R1) was admitted onto Alliance Hospice on 09/30/2025 and passed on 10/12/2025. Resident was prescribed Fentanyl Patch 25 mcg every 72 hours effective 10/07/2025. Facility Medication Administration record shows resident was administered the patch on 10/07/2025 at 1530 and 10/10/2025 at 1530. Facility staff were administering the patch on resident, alternating locations on the body. LPA reviewed Alliance Hospice CONTINUED ON LIC 9099C DATED 11/19/2025
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
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 2
Control Number 22-AS-20251114133858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: DEL'S HAVEN
FACILITY NUMBER: 306005694
VISIT DATE: 11/19/2025
NARRATIVE
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records including admission information, emergency guidelines, care plan and admission orders as well as destruction record and visit notes. LPA reviewed texts provided to the family with hospice visit updates and residents status. Witness 1 (W1) is the Durable Power of Attorney (DPOA) and confirms facility has provided any documents that have been requested and have been responsive the entire time R1 has resided at the facility. LPA reviewed the DPOA paperwork dated 10/03/2024 indicating W1 as the healthcare agent. Two out of two staff and W1 confirm the whole family was present at time of death of the resident. Therefore the allegations are deemed UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. Exit Interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2