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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005928
Report Date: 05/30/2025
Date Signed: 05/30/2025 04:38:01 PM

Unfounded


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
05/13/2025 and conducted by Evaluator Brandon Lopez
COMPLAINT CONTROL NUMBER: 22-AS-20250513174825
FACILITY NAME:MOM'S RETREAT BOARD AND CARE HOMEFACILITY NUMBER:
306005928
ADMINISTRATOR:GILROY, DENISEFACILITY TYPE:
740
ADDRESS:607 S. PINE DRIVETELEPHONE:
(714) 829-6024
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 6DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Administrator Gabriela GarciaTIME COMPLETED:
04:53 PM
ALLEGATION(S):
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Facility refused to accept resident after a hospital visit.
INVESTIGATION FINDINGS:
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On May 30, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to follow up on the investigation into the above allegation and to deliver findings. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Administrator (AD) Gabriela Garcia was notified via telephone and later arrived to assist with the inspection.

The initial complaint investigation visit was conducted on May 20, 2025. During the initial visit, LPA conducted a tour of the physical plant, conducted four staff interviews and conducted six resident interviews. LPA additionally reviewed and collected pertinent documents such as the resident rosters.

Regarding the allegation that, facility refused to accept resident after a hospital visit, the following has been concluded: LPA reviewed the resident roster dated May 1, 2025. LPA observed the individual was not a resident at the facility at this time. CONTINUED ON 9099-C
Unfounded
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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-20250513174825
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: MOM'S RETREAT BOARD AND CARE HOME
FACILITY NUMBER: 306005928
VISIT DATE: 05/30/2025
NARRATIVE
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LPA reviewed the resident roster dated May 15, 2025, and observed the individual was also not a resident at the facility at this time. Four out of four staff interviews conducted also confirmed that the individual has not been a resident at the facility and has not been associated to the facility in anyway. Six out of six resident interviews also confirmed that this individual has not been a resident at the facility. Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Administrator Gabriela Garcia and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2