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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 06:50:44 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-20250117140319
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:
04:25 PM
MET WITH:Lorna SmithTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident was abandonded at the hospital
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit regarding the complaint allegation 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: Resident was abandonded at the hospital

During the complaint investigation, Staff 1 (S1) admitted to abandoning Resident 1 (R1) at the hospital. According to S1, R1 was fine the first day of admission. According to S1, the second day at the facility the resident was observed to be confused and wanted to leave the facility. R1 successfully eloped on third day. The police found the resident and called the facility and asked if they are missing a client. S1 said no and checked on the residents and noticed R1 was not present.

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-20250117140319
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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The police brought the resident back to the facility and S1 informed the family that R1 needed a higher level of care and the family understood. R1 was able to leave the facility a second time and facility staff were alerted by the sound of the auditory exit alarm and were able to catch up with the resident and redirect R1 back to the facility. At that time S1 called the family and informed them they need to find a new facility for R1. The family called the Psychiatric Evaluation Team (PET) to go check on R1 however, the PET said they could not see R1 at the facility (Senior’s Retreat) the resident could only be evaluated in the emergency room. At that time R1’s family called 911 and had the resident sent to the hospital.

According to S1, after a few days the nurse, discharge planner, and the social worker from the hospital called and asked if R1 could return to the facility. S1 admitting to telling hospital staff, R1 could not return because the resident needed a higher level of care.

Based on the evidence gathered through the interview with Staff 1, and observations the preponderance of evidence standard has been met, therefore, the above allegation is 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-20250117140319
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)(3)
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(a) Residents in all residential care facilities... shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... or interfering with daily living functions such as eating, sleeping, or elimination.
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Licensee stated they will read and review regulation sections 87468 (Personal Rights) and regulation section 87224 (Evictions). Licensee will send LPA Haley a signed statement of acknowledgement and understanding upon completion by the POC due date. 1.27.25 at 12 noon.
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This requirement was not being met as evidenced by R1 not being accepted back at the facility after being discharged by the hospital.
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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