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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006096
Report Date: 07/30/2025
Date Signed: 07/30/2025 01:02:41 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
07/23/2025 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250723144514
FACILITY NAME:LOLA SENIOR GUEST HOMEFACILITY NUMBER:
306006096
ADMINISTRATOR:DINH, KEVIN DINOFACILITY TYPE:
740
ADDRESS:8681 LOLA AVENUETELEPHONE:
(714) 300-4540
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:6CENSUS: 5DATE:
07/30/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Kevin DinhTIME COMPLETED:
12:09 PM
ALLEGATION(S):
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Facility did not provide proper care and supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding the complaint allegation above. LPA Haley was greeted, granted entry and explained the reason for the visit upon entering the facility. During the visit LPA interviewed staff, collected and reviewed relevant documents, and toured the facility to make observations.

Regarding the allegation above, 5 of 5 individuals interviewed confirmed the complaint allegation. According to S1, R1 was able to leave the facility and was found by the police and taken to the hospital. S1 was not aware R1 was missing until the morning of July 22, 2025, when hospital staff called the facility around 6:59am and asked if they were missing a resident. S2 says staff were unaware R1 left the facility. According to S2, the last time the caregiver observed R1 was around 7:00pm and then again around midnight. S2 says R1 was sleeping good, and then said R1 was probably just pretending to be sleep when S2 checked on the residents. According to S2, when they woke up sometime in the morning, the caregiver could not locate R1. According to S2, they checked all over the facility before calling S1 to inform them R1 was gone.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
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 3
Control Number 22-AS-20250723144514
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: LOLA SENIOR GUEST HOME
FACILITY NUMBER: 306006096
VISIT DATE: 07/30/2025
NARRATIVE
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Document review revealed, R1 was found by the police around 2:00am on July 22, 2025, and taken to the hospital. R1 has a dementia diagnosis and is not allowed to leave the facility unassisted.

Based on the evidence gathered through interview confirmation and document review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22. An immediate civil penalty of $500 is being assessed.

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

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250723144514
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: LOLA SENIOR GUEST HOME
FACILITY NUMBER: 306006096
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services
(f) Basic services shall at a minimum include: (1) Care and supervision as defined in section 87101(c)(3) and Health and Safety Code Section 1569.2(c). This requirement was not met as evidenced by:
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Administrator Dinh stated he will provide an in-service training for all staff on elopement procedures, caregivers responsibilities, and provide a seven-day schedule for the caregiver who will be assigned to be on duty at night. Administrator Dinh will send a summary of the completed in-service training with a sign-in sheet. The summary breakdown will include the duration of the training and the topics covered during the in-service training. All documents will be emailed to LPA Haley by 4:00pm on the POC due date.
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Based on interview confirmation and document review, R1 was able to leave the facility unassisted in the middle of the night without staff being aware of the residents’ whereabouts, which poses an immediate threat to the residents health and safety.
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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: 07/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3