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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 06:47:14 PM

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
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:
03:45 PM
MET WITH:Lorna SmithTIME COMPLETED:
04:24 PM
ALLEGATION(S):
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Staff caused injury to resident
Facility failed to maintain comfortable temperature for the residents
INVESTIGATION FINDINGS:
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Regarding the complaint allegation: Staff caused injury to resident

During the complaint investigation, 3 of 4 individuals confirmed R1 was dealing with skin irritation on the rectum/bottom area. One witnessed described the skin irritation to be like a diaper rash. The witness claims the facility was provided cream to apply to the affected area. Staff 1 (S1) also confirmed R1 was dealing with irritation to the rectum area from the time R1 was admitted on January 8, 2025. S1 confirmed cream was being applied to the irritated area and it was improving until R1 began having loose stools, which irritated the already sensitive skin around R1’s rectum/bottom area. It is not clear what damage if any was caused by the bag that was placed on the rectum/bottom area as 3 of the individuals interviewed all confirmed R1 was already dealing with skin irritation to the area.

Regarding the complaint allegation: Facility failed to maintain comfortable temperature for the residents

Continued on LIC9099C

Unsubstantiated
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 2
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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During the complaint investigation, it was discovered the facility was having issues with the heater. According to S1, the heater would not properly heat the entire facility. S1 says, the heater would come on, but the entire house was not getting warm enough. S1 claims she called someone to come and repair the heater and they would work on it and the heater would work, but it would malfunction again. The second time the repair man came out the repairs worked, but S1 was advised the repairs were temporary and additional work to the ducts was needed. Eventually the heater stopped working again and two portable were provided until the final repairs were completed. S1 made the necessary repairs on Saturday, January 18, 2025. Receipts were provided.

Based on the information gathered during the investigation through interviews and document review the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations above are deemed Unsubstantiated.
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 2