<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005991
Report Date: 01/13/2026
Date Signed: 01/13/2026 09:48:41 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
09/05/2023 and conducted by Evaluator Hanna Gough
COMPLAINT CONTROL NUMBER: 22-AS-20230905130429
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: 36DATE:
01/13/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Paige RohrerTIME COMPLETED:
09:48 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent a resident from developing a pressure injury.
Staff did not administer medication to a resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to investigate the above mentioned complaint allegation. 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 allegation of staff did not prevent a resident from developing a pressure injury revealed the following: Resident #1(R1) was admitted to the facility on March 20, 2022. LPA observed a physicians report for R1 dated March 20, 2022, stating that R1 had no history of a skin condition/breakdown and that they were able to communicate their needs. R1 was marked as ambulatory on the physicians report. LPA did not observe an updated physicians report for R1. LPA observed a functional capability assessment for R1 dated April 2, 2023, stating that R1 needed full assist with bathing, dressing, toileting, transferring, eating, grooming and repositioning. LPA observed that R1 was noted to be able to make their needs known.
Continue on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026
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-20230905130429
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: 01/13/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This assessment was signed by facility personnel only. LPA observed outside agency progress notes for R1 dated June 7, 2023 to July 24, 2023 from Kaiser home health personnel to provide stage 2 wound care on R1s coccyx . LPA observed home health personnel to notate the wound to be a stage 3 pressure wound on June 16, 2023 with notes of instruction to staff on ADLs with no other changes. LPA observed notations of no new wounds or significant changes for R1 throughout the home health personnel documents. LPA observed notations on July 7, 2023, noting instructions for facility staff and that the wound is improving. On July 12, 2023 home health personnel noted that R1 was improving with positive skin growth to the wound. LPA observed notations from home health personnel that R1s wound had healed and wound care was to be discontinued on July 24, 2023. LPA did not observe home health documents from April of 2023 due to the facility not having the documents.

LPA interviewed staff regarding R1s pressure wound and three of five staff could not recall or did not know about R1s pressure wound. One of five staff remembered a home health agency coming to the facility for R1 but could not recall why. One of five staff informed LPA that they remembered R1 having bed sores but could not recall if R1 received home health services due to the pressure wound.

The Department interviewed staff in September of 2023 that stated R1 received all their medications even if they had to dispense the medication themselves.

LPA interviewed five staff regarding R1s medication administration and five of five staff could not recall or did not know about R1s medications. One of five staff informed LPA that they did not dispense medications to R1 due to not having to dispense any medications during the night shift. Two of five staff informed LPA that they do not dispense medications to residents in care.

LPA observed current client medications and observed that they were being given as prescribed.

LPA interviewed three of three residents in care and was informed that they receive all their medications as prescribed with no issues. LPA was unable to interview R1 due to not being at the facility anymore.

Although it was alleged that staff did not prevent a resident from developing a pressure injury, LPA was unable to review all home health records due to the facility not retaining resident documentation from April of 2023 along with facility notes pertaining to needs and services provided by the facility and the progression of R1s wounds. This allegation has been deemed UNSUBSTANTIATED.

Continue on LIC9099C

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

DATE: 01/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230905130429
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: 01/13/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Although it was alleged that staff did not administer medication to a resident in care LPA was unable to review R1s physicians orders or medication administration record due to the facility not retaining resident documentation. This allegation has been deemed UNSUBSTANTIATED.

Based on information gathered, interviews and record review, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred: Therefore, the allegations are deemed UNSUBSTANTIATED.

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: 01/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3