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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005991
Report Date: 05/20/2025
Date Signed: 05/20/2025 11:59:21 AM

Unsubstantiated


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
12/06/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 22-AS-20231206162230
FACILITY NAME:GARDEN GROVE GUEST HOME LLCFACILITY NUMBER:
306005991
ADMINISTRATOR:TISTOJ, RUTHFACILITY TYPE:
740
ADDRESS:12882 SHACKELFORD LANETELEPHONE:
(714) 638-9470
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:47CENSUS: 34DATE:
05/20/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:CONNOR KELLEYTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff neglect resulted in a resident sustaining multiple fractures while in care.
INVESTIGATION FINDINGS:
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On 05/19/25, Donna Gurriere, Licensing Program Analyst (LPA) contacted the licensee/administrator via telephone to deliver final findings regarding a complaint that was received 12/06/2023. LPA Gurriere spoke with Connor Kelley, Administrator and explained the purpose of the call.

Staff neglect resulted in a resident sustaining multiple fractures while in care.


During the interview process, the administrator, assistant administrator, four staff persons and two doctors were interviewed. In addition, documents were reviewed and obtained to include the Physicians Report, Incident Report, Death Certificate, and Medical Records of the resident (Resident 1).


continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
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-20231206162230
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: GARDEN GROVE GUEST HOME LLC
FACILITY NUMBER: 306005991
VISIT DATE: 05/20/2025
NARRATIVE
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During the investigation of a complaint received on 12/06/23 it was reported that the medical records from Fountain Valley Hospital indicated that the resident presented at the hospital on 11/27/2023 with apparent abdominal discomfort for three days prior to admission. Upon initial evaluation, the resident underwent abdominal ultrasound demonstrating a 6-m nonobstructive right kidney stone with no other significant findings. The resident was found to have concerns for displaced rib fractures along the right lateral aspect of the ribs seven and eight. The displaced rib fractures may be either acute or subacute and not chronic. There is no documented history of falls. The medical records also indicated the fractures may be contributing to her abdominal discomfort as referred pain.

Based on the information gathered during the investigation, there is not enough corroboration and or evidence to show that there is neglect/lack of care or supervision for the resident.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.

Licensee or administrator was advised a copy of this report will be sent via certified mail. Two copies of the report will be sent. Licensee or administrator is to sign and return a copy to the Orange County Regional Office.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2