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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005914
Report Date: 03/20/2026
Date Signed: 04/28/2026 08:36:29 AM

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
01/16/2026 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20260116161217
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: DATE:
03/20/2026
UNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Lorna Smith, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff left resident in soiled diaper for a period of time.


***This is an amended report.***
INVESTIGATION FINDINGS:
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LIcensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility to investigate a complaint received in the Regional Office. LPA was greeted and granted entry by Lorna Smith and explained the purpose of the visit.

LPA reviewed the following documents for Resident #1 (R1): Identification and Emergency Information Form, Physician's Report, Hospice paperwork, and Progress Notes. The Physician' s Report from January 6, 2026 states R1's diagnosis is Neurocognitive disorder with Lewy bodies, that the resident was not ambulatory and required a walker and wheelchair. The assessment states R1 must have 24/7 supervision and assistance with Activities of Daily Living (ADLs) and medications. R1 required two person assist for transfers. Resident received hospice services upon admission to the facility on December 14, 2025. R1 had recently started hospice services on December 3, 2025. Resident changed hospice agencies on December 29, 2025.
(Continued on LIC 9099-C)



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026
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-20260116161217
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: 03/20/2026
NARRATIVE
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(Continued from LIC 9099)
It was alleged that Staff left resident in soiled diaper for a period of time. Staff interviews reported that the routine was to check R1's diaper at 6am. R1 would be bathed by the hospice bath aide between 7-8:30am and breakfast would be at 9am. After breakfast R1 would "walk" in the wheelchair outdoors if weather permitted. After lunch the diaper would be checked and R1 would take a nap. R1 would awaken before dinner and, after dinner, R1 would return to the bedroom to watch television. Staff reported R1 did not have any rashes and did not sit in soiled diapers. Staff tried to keep R1 busy throughout the day so R1 would sleep better at night. R1 would be restless and get out of bed at night. The allegation that Staff left resident in soiled diaper for a period of time is Substantiated.

R1 changed hospice agencies on December 29, 2025. On January 1, 2026, a witness stated R1 had a soiled diaper from 6am. The witness arrived at 9am and asked staff why R1 had not been changed. AD stated they had expected the hospice bath aide, who normally arrived between 7:30 to 8am. The facility reached to the hospice agency and were told the aide had called off and someone would be arriving. The bath aide did not arrive until noon. Two of two witnesses confirmed the allegation that Staff left resident in soiled diaper for a period of time. Two of three staff confirmed the allegation but one staff member was not present and could not confirm nor deny the allegation.

Based on LPA record review and interviews, the preponderance of evidence standard has been met. Therefore the allegation that Staff left resident in soiled diaper for a period of time is Substantiated. The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Lorna Smith, Administrator and a copy of this report was given to the facility along with a copy of the LIC 811, LIC 9099-D and Appeal Rights.

***This is an amended report.***
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260116161217
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: 03/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2026
Section Cited
CCR
87464(f)(4)
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87464 (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing... This requirement is not met
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AD stated staff will be in-serviced and documentation, dated and signed by staff, will be emailed to LPA by POC due date.
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(cont'd) as evidenced by: Based on LPA interviews one of four residents was in a soiled diaper for a period of time. This poses an immediate health and safety risk for 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: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3