306006054-9-4-2025-22-AS-APAO-DLE6QZ-20250910210133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006054
Report Date: 09/04/2025
Date Signed: 09/04/2025 11:55:51 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/02/2025 and conducted by Evaluator Claudia Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250902145332

FACILITY NAME:	PAGEANTRY COTTAGE, THE		FACILITY NUMBER:	306006054
ADMINISTRATOR:	JABONERO, MACRINA		FACILITY TYPE:	740
ADDRESS:	125 PAGEANTRY DR		TELEPHONE:	(714) 504-5371
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 4	DATE:	09/04/2025
		UNANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:	Macrina Jabonero		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident was forced to take PRN medication
Resident was physically abused by staff

INVESTIGATION FINDINGS:

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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Administrator (AD) Macrina Jabonero and explained the purpose of the inspection.

Regarding the allegation Resident was forced to take PRN medication, the following was revealed: It is alleged R1 is being forced to take PRN medication. During the course of the investigation, interviews were conducted with R1, two additional facility residents, and two staff. During their interview, R1 denied ever being forced to take to any medication, including PRNs. Per R1, staff provide their medication to them by placing it in a medication cup and handing it to them, they then independently take the medication orally. During their interview, Resident 2 (R2) was unable to confirm or deny the allegation, however, LPA did observe R2 was provided with their medication, which was placed in a medication cup by staff. LPA then observed R2 take medication orally and independently. During their interview, Resident 3 (R3) denied the allegation and stated they have never been forced to take their medication and denied witnessing staff forcing any other resident to take their medication. (Cont. LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

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-20250902145332

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PAGEANTRY COTTAGE, THE	FACILITY NUMBER: 306006054
	VISIT DATE: 09/04/2025

NARRATIVE

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During their interview, Staff 1 (S1) denied ever personally forcing R1 or any other resident to take their medication. S1 also denied witnessing or having any knowledge of any other staff forcing any resident to take their PRN medication or any other medication. During their interview, AD denied staff force R1 or any other resident to take their medication and stated R1 is able to take medication independently without staff intervention.

Regarding the allegation Resident was physically abused by staff, the following was revealed: It is alleged staff physically hold R1’s hands or hit R1 if R1 does not comply with taking PRN medication. During their interview, R1 denied ever being physically abused by staff and denied staff hitting them or holding their hands in order to get them to take PRN medication. During their interview, Resident 2 (R2) was unable to confirm or deny the allegation. During their interview, Resident 3 (R3) denied being personally hit by any staff and denied witnessing or having any knowledge of staff physically abusing or hitting any other resident. During their interview, Staff 1 (S1) denied ever personally hitting R1 or any other resident and denied witnessing or having any knowledge of staff physically abusing or hitting any resident. During their interview, AD denied personally hitting R1 or any other resident. AD also denied witnessing or receiving any reports of staff physically abusing or hitting any resident.

Due to allegations being uncorroborated during interviews conducted, the Department is unable to determine if Resident was forced to take PRN medication or if Resident was physically abused by staff. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore at this time the above allegations are unsubstantiated.

An exit interview was conducted and copy of this report was provided at the end of the inspection.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

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