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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006057
Report Date: 10/28/2025
Date Signed: 10/28/2025 07:01:05 PM

Substantiated


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
10/20/2025 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251020134502
FACILITY NAME:SOLIVEN CARE HOMEFACILITY NUMBER:
306006057
ADMINISTRATOR:SOLIVEN, JOSELOLITOFACILITY TYPE:
740
ADDRESS:6710 SEQUOIA DR.TELEPHONE:
(714) 310-9293
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: 5DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Joselolito SolivenTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility failed to report and provide updates on the residents health status.
INVESTIGATION FINDINGS:
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Regarding the allegation: Facility failed to report and provide updates on the residents health status.

During the investigation, it was confirmed by S1, there was a breakdown in communication and the family of R1 was not informed about the residents change in condition. Facility staff did not inform the responsible person about the swelling to the residents legs that led to the residents hospitalization. S1 also confirmed there was no incident report sent to the Regional Office regarding the hospitalization of R1.

Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the allegation above is found to be SUBSTANTIATED. A violation is being cited per California Code of Regulations Title 22.

An exit interview was conducted, and a copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
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-20251020134502
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: SOLIVEN CARE HOME
FACILITY NUMBER: 306006057
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2025
Section Cited
CCR
87211(1)(D)
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87211 Reporting Requirements
(1) A written report shall be submitted... within seven days of the occurrence of any of the events specified... below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not being met as evidenced by:

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Licensee Soliven agrees to review the reporting requirements and email LPA Haley a signed statement of acknowledgement and understanding of the reporting requirements. Licensee Soliven will also inform LPA who will be the primary person responsible for reporting incidents to the department and the back up person responsible, in case the primary person is unavailable. POC is due by 4:00pm on the POC due date.
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The admission by Licensee Soliven, that the responsible party was not notified regarding R1’s change in condition and there was no incident report sent to the department regarding R1’s hospitalization.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2