306005865-7-29-2025-22-AS-AORZ-DK2UAW-20250729152525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005865
Report Date: 07/18/2025
Date Signed: 07/29/2025 08:31:08 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
03/18/2025 and conducted by Evaluator RoseMarie Ruppert

COMPLAINT CONTROL NUMBER: 22-AS-20250318101709

FACILITY NAME:	RESPIT MANOR		FACILITY NUMBER:	306005865
ADMINISTRATOR:	MENDEZ, MARK		FACILITY TYPE:	740
ADDRESS:	23255 RESPIT AVE		TELEPHONE:	(949) 460-0317
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	07/18/2025
		UNANNOUNCED	TIME BEGAN:	08:21 AM
MET WITH:	Mark Mendez, Administrator (AD)		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff inappropriately fondled resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility regarding a complaint received in our Regional Office on March 18, 2025. LPA was greeted and granted entry by staff and met with Administrator (AD) Mark Mendez.

On March 19, 2025 LPA toured the facility and conducted a health and safety check on five residents LPA obtained the following from resident files: Emergency ID Facesheet, Needs and Appraisal Services, and Physician's Reports. LPA also obtained handwritten Unusual Incident Report from March 14, 2025 and staff clearance information.

An incident report was filed with the Department on March 14, 2025 from AD Mendez which reported an incident on 03-13-25 at around 6 PM in which staff stated (staff) was cleaning resident 1 (R1) under breast as there are rashes present, staff was wiping (with) wipes while R1 and staff was having a conversation. At (Continued on LIC 9099) ****This is an amended report.****

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

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-20250318101709

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: RESPIT MANOR	FACILITY NUMBER: 306005865
	VISIT DATE: 07/18/2025

NARRATIVE

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(Continued from LIC 9099)
around 8 PM night staff called Administrator and reported that R1 was touched inappropriately by staff while being cared for.

On March 18, 2025, four days later, the RO received a complaint alleging Staff inappropriately fondled resident.. The Department conducted joint visits with the Orange County Sheriff (OCS) Investigator regarding the complaint. On March 28, 2025, the an interview was conducted with R1 at R1's new place of residence. R1’s file was reviewed.

On April 24, 2025, the Department spoke to Staff #1 (S1) and obtained a statement. S1 stated to investigators that R1’s top was taken off, and S1 applied powder to a rash underneath the resident’s breasts. Caregiver said they wore gloves, and first asked the resident permission to apply the powder. The resident gave permission, and S1 applied the powder.

The Department reviewed hospice records in which notes on March 11, 2025 that R1 had a slow decline In the last 2 months and was able to verbalize their needs. R1 remained bed bound and had a rash to Bilateral breasts that is being treated with nystatin powder TID (three times per day) that has been effective.

On July 18, 2025, LPA Ruppert interviewed Staff #2 (S2), who had worked with Staff #1 on the day the incident occurred. S2 stated they had been surprised at the allegation since R1 had been treated with Nystatin powder for several weeks by S1. S2 had also interacted with R1 on the date of the incident and the resident did not share any concerns with S2.

LPA also interviewed two of two residents who resided at the facility at the time of the incident. Resident #2 (R2) stated they have, "...never been inappropriately touched. These people are gifts. They care, are attentive and responsive." R2 could not recall the caregiver in question but has had no issues with staff.

LPA interviewed Resident #3 (R3) and asked if R3 remembered anything about Staff #1 (S1). R3 nodded yes when LPA stated the staff member's name. When asked if R3 had ever been inappropriately touched by staff members or S1, R3 shook head with a "No." LPA inquired about R3's stay at the facility and if R3 liked the food and was assisted when needed. R3 nodded with a yes to all three questions.

(Continued on LIC 9099-C1) ****This is an amended report.****

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250318101709

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: RESPIT MANOR	FACILITY NUMBER: 306005865
	VISIT DATE: 07/18/2025

NARRATIVE

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(Continued from LIC 9099C)

Based on the totality of the circumstances, there was a documented medical need for caregivers to apply medication powder to R1’s breasts. Based on the Department’s review of records, interviews and observations, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation did or did not occur. Therefore the allegation that: Staff inappropriately fondled resident, is Unsubstantiated. An exit interview was conducted with AD Mark Mendez and a copy of this report was provided to the facility.

****This is an amended report.****

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

LIC9099 (FAS) - (06/04)

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