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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005865
Report Date: 10/28/2025
Date Signed: 11/06/2025 03:08:57 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
10/24/2025 and conducted by Evaluator Celine Rodriguez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251024105308
FACILITY NAME:RESPIT MANORFACILITY NUMBER:
306005865
ADMINISTRATOR:MENDEZ, MARKFACILITY TYPE:
740
ADDRESS:23255 RESPIT AVETELEPHONE:
(949) 460-0317
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 6DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Facility Administrator - Mark MendezTIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Staff did not provide a refund upon resident’s death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced 10-day visit to the facility for the complaint and to deliver the findings. LPA Rodriguez explained the purpose of today's visit, was greeted, and granted entry by staff on duty, who contacted facility administrator (AD) Mark Mendez. At 11:00AM, AD Mendez arrived and met with LPA.

During the investigation, LPA Rodriguez toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed.

It was alleged that staff did not provide a refund upon resident’s death. 1 out of 1 staff (S1) interview corroborated with the allegation by providing direct admission that facility has not paid resident (R1) family with the money owed due to unforeseen circumstances, however disclosed plans on issuing a check on 10/29/25.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
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-20251024105308
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2025
Section Cited
HSC
1569.657(a)(5)(A)
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Health and Safety Code section 1569.657 provides:
(a) …The notice shall include…
(5) Refund conditions.
(A) ...Will be returned in the event of a resident’s death…
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As a plan of correction (POC) facility is to issue the refund to R1's family in the amount of $1,122.54 by 10/29/25.
Facility is to provide proof to assigned LPA on 10/29/25.
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This requirement is not met as evidence by:
Based on LPAs review of documents, interviews and observations, facility administrator provided direct admission that the refund was not issued. This poses a potential health and safety risk to residents in care.
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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: Sheila Santos
LICENSING EVALUATOR NAME: Celine Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20251024105308
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: 10/28/2025
NARRATIVE
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Based on LPA’s interviews which were conducted, review of documents obtained, and observations, the preponderance of evidence standard has been met, therefore the allegation is SUBSTANTIATED.

An exit interview was conducted with AD Mendez.



A copy of this report was explained, and appeal rights were provided during the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3