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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005914
Report Date: 04/28/2026
Date Signed: 04/28/2026 09:07:07 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: 5DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Lorna Smith, AdministratorTIME COMPLETED:
09:20 AM
ALLEGATION(S):
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Staff restrain resident in chair.
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 Administrator (AD) Lorna Smith at 8am and explained the purpose of the visit. Currently there are five residents in care.

LPA reviewed the following documents for Resident #1 (R1): Identification and Emergency Information Form, Physician's Report, Hospice paperwork and orders, Admission Agreement, Centrally Stored Medication Log, Medication Administration Record, Progress Notes and Medication Release Record from the prior facility. The Physician's Report form 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. Resident received hospice services upon admission to the facility on December 14, 2025. R1 had recently started hospice services on December 3, 2025. R1 required two-person assist for transfers.
(Continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
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: 04/28/2026
NARRATIVE
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(Continued from LIC 9099)

It was reported that Staff restrain resident in chair. LPA reviewed the Physician's Report and Hospice Paperwork and orders. R1 came to the facility from the hospital and was transported via ambulance on a gurney. R1 is a two-person assist. R1 has a history of six falls from the prior facility and a wheelchair with a seat belt, as well as a walker, were provided. A geri-chair recliner was ordered and provided by the hospice agency. The geri chair is able to fully recline to a bed; which assisted staff in changing diapers. Since R1 was a two-person assist, instead of moving R1 from a chair to R1's bed; the geri-chair was used. A request for an exception for the geri-chair was not received by the Department.

Upon interview, three of three staff denied that Staff restrain resident in chair but did report the resident often tried to get out of the chair and was a fall risk. Three of three staff confirmed the chair was reclined so resident was unable to get up from chair. Therefore, the geri-chair was intentionally being reclined in an effort to restrain resident from getting up from the chair. One of two witnesses confirmed the allegation. One of two witnesses did 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 restrain resident in chair is Substantiated. The following deficiencies are 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.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
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: 04/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2026
Section Cited
CCR
87608(a)(5)
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Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself...(5) Under no circumstances shall…
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POC: Resident has moved. LPA spoke with AD regarding geri-chair use requiring an exception from the Department. AD will read Postural Support regulations and email LPA a signed Memo of Understanding. AD will also in-service staff on restraints by the POC due date and email documentation to LPA.
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postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement was not met as evidenced by: Based on witness and staff interviews a geri-chair was used to restrain a resident which poses a potential health and safety risk.
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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: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
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