306005743-7-29-2025-22-AS-LMOA-DKSTCF-20250822143640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005743
Report Date: 07/29/2025
Date Signed: 07/29/2025 08:50:26 AM

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
02/25/2025 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250225150251

FACILITY NAME:	ASSURED CARE VILLA		FACILITY NUMBER:	306005743
ADMINISTRATOR:	DOMPREH-MENSAH, THERESA		FACILITY TYPE:	740
ADDRESS:	561 EAST SECOND AVE		TELEPHONE:	(310) 650-4190
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	6	CENSUS: 5	DATE:	07/29/2025
		UNANNOUNCED	TIME BEGAN:	07:00 AM
MET WITH:	Theresa Dompreh-Mensah- Administrator Loreta Angeles- Caregiver		TIME COMPLETED:	09:00 AM

ALLEGATION(S):

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Staff caused injury to resident while in care.
Staff forced resident to take a shower.
Staff prohibited a resident from placing a call to a family member.

INVESTIGATION FINDINGS:

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On July 29, 2025, Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of delivering the investigation findings into the above allegations. LPA was greeted and granted entry by Caregiver Loreta Angeles and informed Administrator Theresa Dompreh-Mensah by telephone explaining the reason for the visit.

On February 25, 2025, the Department received a complaint alleging a violation of personal rights and physical abuse of Resident #1 (R1). The investigation was initiated by the Department on February 26, 2025, followed by a subsequent visit on July 1, 2025. During the course of the investigation, the Department interviewed six residents, five staff, and obtained the following documentation: Resident Rosters, Personnel Reports, Shower Schedule, Staff Tasks, Face Sheets, Physician’s Reports for all residents as well the Incident Report (LIC624) dated February 25, 2025 regarding R1, Admission Agreement dated November 22, 2022, Needs and Services Plan dated January 10, 2025, Care Notes from January 22, 2025 to February 23, 2025 for R1...,

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

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-20250225150251

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: ASSURED CARE VILLA	FACILITY NUMBER: 306005743
	VISIT DATE: 07/29/2025

NARRATIVE

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discharge summary dated February 23, 2024, and the police report.

Regarding the allegation, Staff caused injury to resident while in care, it was reported that on February 23, 2025, a staff handled R1 in a rough manner by forcefully grabbing R1 by their left arm forcing resident to shower resulting in a fractured left pinky finger. The investigation is as follows: R1 is diagnosed with Cerebral Palsy per the Physician’s Report dated March 14, 2024 and is limited in their communication. LPA attempted to interview R1 however, LPA was unable to qualify due to their medical condition. In R1’s statement to the police, R1 was questioned if they could demonstrate how the injury was sustained, however R1 was only able to illustrate by gesture by manipulating the bed rail. R1 was unable to provide any clear response. Based on the interviews, two out of the six residents who resided at the facility with R1, indicated not witnessing or having knowledge of other residents being harmed. The remaining two residents were not registered to the facility at the time when the incident occurred while one resident interview was attempted but unable to qualify due to their medical condition. Two out of the five staff who were present on the morning of Sunday, February 23, 2025, indicated R1 was agitated when R1 was asked to shower by Staff #1 (S1). Staff #2 (S2) indicated rushing to R1’s room after hearing a loud bang and observed R1 lying down in bed holding the bed rails on each side shaking vigorously causing the bed to hit against the wall. S2 observed (S1) standing by the corner of the bed away from R1 verbally calming R1 who was flailing their body and kicking the air at the time. S1 and S2 indicated that the movement of the bed had caused R1 to injure their hand in between the wall and bed rail. R1’s representative did not provide clear evidence of how the injury was caused by staff and later confirmed that R1 suffered a finger sprain in lieu of a fracture to the left pinky and was placed with a splint. R1's representative stated that per the urgent care doctor, the finger appeared as if it had been smashed or banged against something or bracing self during a fall. The Kaiser medical discharge summary dated February 23, 2024, corroborated the finger sprain.

Regarding the allegation, Staff forced resident to take a shower, the investigation revealed: Based on the review of R1’s physician’s report, R1 requires assistance with showering as R1 is unable to bathe self. On the admission agreement dated November 22, 2022, bathing is included under Basic Services. The shower schedule posted on the kitchen bulletin board documented R1 receiving a shower every Tuesday evening. However, the facility provides showers every day as requested by R1’s representative as confirmed by five out of the five staff. Five out of five staff and four out of six residents indicated showers were not forced. Interviews with the remaining two residents were attempted, however unable to qualify due to their medical conditions.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20250225150251

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: ASSURED CARE VILLA	FACILITY NUMBER: 306005743
	VISIT DATE: 07/29/2025

NARRATIVE

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Five out of the five staff indicated that residents, including R1, have the right to refuse showers and are never forced. In the Needs and Services Plan, R1 is noted to display frequent explosive episodes of behavioral outbursts which may become aggressive at times and protests by crying to avoid non-preferable tasks. Five out of the five staff confirmed R1 disliking showers and encourages R1 to shower and educates the importance of personal hygiene.

Regarding Staff prohibited resident from placing a call to a family member, it was reported that R1 was restricted from using their personal cell phone. The investigation revealed the following: There is no written rule regarding placing personal phone calls in the evenings, however there is an implied rule per five out of five staff. Based on the interviews, five out of five staff and three out of five residents confirmed residents were able to use the phone during the day with some limitations in the evening out of consideration for other residents who may be sleeping. The three residents indicated that they chose not to use the phone in the evenings and preferred to sleep. Interviews with the remaining two residents were attempted, however unable to qualify due to their medical conditions. Regarding R1’s phone use, five out of five staff indicated that R1 was able to use their phone during the day without having any limitations, however, was refrained most of the time from using their cell phone after 9pm. Based on the interview with R1’s representative, facility was instructed not to allow R1 to place calls to them after 9pm.

Based on observations, interviews, and record review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore all allegations are deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Theresa Dompreh-Mensah by telephone and consented facility staff to sign the report on their behalf.

A copy of this report including the LIC811 were left with Caregiver Loreta Angeles.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

LIC9099 (FAS) - (06/04)

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