306005928-9-5-2025-22-AS-APAO-DLP7EP-20250919213617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005928
Report Date: 09/05/2025
Date Signed: 09/05/2025 10:17:45 AM

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
08/29/2025 and conducted by Evaluator Brandon Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250829150212

FACILITY NAME:	MOM'S RETREAT BOARD AND CARE HOME		FACILITY NUMBER:	306005928
ADMINISTRATOR:	GILROY, DENISE		FACILITY TYPE:	740
ADDRESS:	607 S. PINE DRIVE		TELEPHONE:	(714) 829-6024
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	6	CENSUS: 6	DATE:	09/05/2025
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator Gabriela Garcia		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff abandoned resident
Staff did not seek timely medical attention
Staff did not ensure medication was dispensed as prescribed

INVESTIGATION FINDINGS:

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On September 5, 2025, Licensing Program Analysts (LPAs) Brandon Lopez and Garlli Tat made an unannounced visit to the facility to initiate the investigation into the allegations listed above and to deliver findings. LPAs were 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.

On today's visit, LPAs conducted a tour of the physical plant, conducted four staff interviews and conducted six resident interviews. LPAs additionally reviewed and collected pertinent documents such as the resident rosters.

Regarding the allegations that, staff abandoned resident, staff did not seek timely medical attention, and staff did not ensure medication was dispensed as prescribed, the following has been concluded: LPAs reviewed the resident roster dated July 5, 2025. CONTINUED ON LIC9099-C

Unfounded

Estimated Days of Completion: 90

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250829150212

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: 09/05/2025

NARRATIVE

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LPA observed the individual was not a resident at the facility at this time and that the residents listed on the roster have not changed since that date. 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: 09/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

LIC9099 (FAS) - (06/04)

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