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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005914
Report Date: 01/24/2025
Date Signed: 01/24/2025 06:45:37 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
01/17/2025 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250117100656
FACILITY NAME:SENIOR'S RETREAT, INC.FACILITY NUMBER:
306005914
ADMINISTRATOR:SMITH, LORNAFACILITY TYPE:
740
ADDRESS:312 GUAVA PLACETELEPHONE:
(714) 332-0685
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 4DATE:
01/24/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Lorena SmithTIME COMPLETED:
03:44 PM
ALLEGATION(S):
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Staff applied a colostomy bag without a doctor's order
Facility heater is inoperative
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit regarding the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit upon entry. Before interviews began, LPA toured the interior and exterior portion of the facility with Staff 1 (S1).

Regarding the complaint allegation: Staff applied a colostomy bag without a doctor's order

During the complaint investigation 3 of 4 individuals interviewed provided information that confirms the complaint allegation, including Staff 1(S1) who admitted to placing a bag on the residents rectum/bottom area.

S1 admitted to placing the colostomy bag on the resident 1’s rectum/bottom area. According to S1, R1 was dealing with a lot of “loose stool” so S1 used the colostomy bag to catch the loose stool to prevent further damage to R1’s already compromised skin area on the rectum/bottom area.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
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-20250117100656
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: SENIOR'S RETREAT, INC.
FACILITY NUMBER: 306005914
VISIT DATE: 01/24/2025
NARRATIVE
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According to S1, R1’s rectum area was already damaged and the bag wouldn’t even stick to R1’s bottom area. S1 claims the area on R1 was not a bed sore, but it was a little worse than a diaper rash. According to S1, the acid in R1’s loose stool could cause the skin to open and create a sore.

Regarding the complaint allegation: Facility heater was not in operating condition.

3 of 4 individuals interviewed provided information the supports the complaint allegation. Including Staff 1 (S1) who admitted the facility heater was not functioning properly. According to S1 the duct needed to be replaced or repaired. S1 provided documents to show the heater was repaired on Saturday, January 18, 2024. At the time of the complaint visit (1.24), S1 adjusted the thermostat and turned on the heater. LPA Haley verified warm air coming out the vent during the visit.

Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegations are SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250117100656
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: SENIOR'S RETREAT, INC.
FACILITY NUMBER: 306005914
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Licensee stated they will read and review regulation sections 87468 (Personal Rights). Licensee will send LPA Haley a signed statement of acknowledgement and understanding upon completion.
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This requirement is not being met as evidenced by S1 admitting to using a colostomy bag on the rectum/bottom area of Resident 1 to prevent loose stool from causing additional damage to the residents’ skin area that was already damaged and being treated.
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Type B
01/27/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The facility heater has already been repaired. LPA verified the heater is in good working condition during the complaint visit. No further action necessary.
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This requirement was not met as evidenced by S1 admitting to having issues with the facility heater heating the entire facility. S1 arranged for major repairs to the heating system January 18, 2025 and provided receipts.
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3