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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005991
Report Date: 12/12/2025
Date Signed: 12/12/2025 12:42:39 PM

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
04/30/2024 and conducted by Evaluator Hanna Gough
COMPLAINT CONTROL NUMBER: 22-AS-20240430125543
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: 40DATE:
12/12/2025
UNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Paige RohrerTIME COMPLETED:
12:42 PM
ALLEGATION(S):
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Resident sustained unexplained bruising while in care
Staff did not seek timely medical attention for a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to investigate the above mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with Assistant Administrator (AA) Paige Rohrer and discussed the purpose of the visit.

The investigation into the facility allegations of resident sustained unexplained bruising while in care and staff did not seek timely medical attention for a resident revealed the following: Resident #1 (R1) was admitted to the facility October 18, 2023. LPA observed a physicians report dated October 18, 2023, stating that R1 had a diagnosis of dementia and had motor impairment with a note of using a roller walker. R1 did not have a history of a skin condition/breakdown. R1 was noted as non ambulatory due to their physical condition. LPA observed a needs and services plan dated October 18, 2023, stating that R1 was returning from a skilled nursing facility due to a fall. The needs and services plan noted that R1 had no physical disabilities and was able to walk safely with their walker and will be evaluated through reports if falls or injuries happen. Continue on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
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-20240430125543
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: 12/12/2025
NARRATIVE
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LPA did not observe any incident reports of progress notes for R1.

The Department interviewed four staff in May of 2024 and it was revealed that four of four staff stated the bruising was noted between April 25, 2024, and April 28, 2024. R1 was sent to the hospital on April 28, 2024, due to the bruising around their eyes becoming darker. Four of four staff stated that R1 was not sent out when it was first noticed due to R1 refusing. R1 agreed to go to the hospital on April 28, 2024 due to the bruising around their eyes getting darker.

During interviews with four of five staff informed LPA that they do not remember bruising on R1. Three of five staff informed LPA that they did not remember if R1 was sent to the hospital. One of five staff informed LPA that they remembered R1 going to the hospital but did not recall what for and when it was. One of five staff was not at the facility at the time of the incident.

LPA observed updated staff training's on resident care and when to report to a medication technician on March 1, 2025.

Although the above allegations may have happened there is not a preponderance of evidence to prove the alleged violations occurred; therefore, the allegations that resident sustained unexplained bruising while in care and staff did not seek timely medical attention for a resident are deemed UNSUBSTANTIATED. Therefore, the Department dismisses the allegations.

An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2