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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006118
Report Date: 06/18/2025
Date Signed: 06/18/2025 04:03:15 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
06/16/2025 and conducted by Evaluator Edward Kim
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250616162420
FACILITY NAME:HILLS OF SHAY DEL, THEFACILITY NUMBER:
306006118
ADMINISTRATOR:NEPOMUCENO, MARICELFACILITY TYPE:
740
ADDRESS:5982 SHAY DEL PLACETELEPHONE:
(626) 827-9547
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 6DATE:
06/18/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator- Joanna GomezTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility did not issue a refund
INVESTIGATION FINDINGS:
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On June 18, 2025, at 9:20 AM Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit at the facility. LPA Kim met with Administrator (ADMIN) Joanna Gomez and explained the purpose of the visit.

During today's visit, LPA Kim conducted a tour of the indoor and outdoor physical plant with ADMIN Gomez, and no concerns were observed. LPA Kim reviewed and obtained copies of the following records: Resident/Staff Rosters, Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, and other pertinent records for one (1) resident as well as the Personnel Report, Health Screening, training, and other pertinent records for two (2) staff. LPA Kim also conducted three (3) staff interviews.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
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 5
Control Number 22-AS-20250616162420
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: HILLS OF SHAY DEL, THE
FACILITY NUMBER: 306006118
VISIT DATE: 06/18/2025
NARRATIVE
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Allegation: Facility did not issue a refund

It is alleged that a Resident #1 (R1) has not received a refund for over $1000 after moving out. R1 had notified facility 30 days and did not receive the refund to this date.

Based on observation, LPA verified that R1 no longer resides at the facility via the Resident Roster dated June 16, 2025. R1 moved out on May 24, 2025.

Based on record review, the Admission Agreement dated April 12, 2025, states “the total monthly rate will be prorated/refunded upon the resident’s admission or departure from the facility during the month provided the resident has given an appropriate 30-day notice in writing to vacate.” LPA Kim conducted three staff interviews. One out of the three staff interviews confirmed that the refund was not issued to the resident while a second staff confirmed receiving a text notification that R1 would move out on May 24, 2025. Per review of the billing invoice shows the resident paid for the month of May, but an invoice for the refund was not issued, which corroborates the allegation.

Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility did not issue a refund is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. A deficiency is being cited on the attached LIC9099D.

Exit interview was conducted, and a copy of the report, LIC9099D, LIC811, and the appeal rights were provided to Administrator Joanna Gomez
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20250616162420
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: HILLS OF SHAY DEL, THE
FACILITY NUMBER: 306006118
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2025
Section Cited
HSC
1569.652(c)
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1569.652(c)A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual... within 15 days.
This requirement is not met as evidenced by:
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Licensee states they will send a refund to R1 for $1174.19 and send proof of copy to CCLD via email to Edward.kim@dss.ca.gov by POC due date July 2, 2025.
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Based on observations record review, and interviews, facility did not issue a refund of $1174.19 to the resident which poses a potential personal rights risk to persons in care.
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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: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/16/2025 and conducted by Evaluator Edward Kim
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250616162420

FACILITY NAME:HILLS OF SHAY DEL, THEFACILITY NUMBER:
306006118
ADMINISTRATOR:NEPOMUCENO, MARICELFACILITY TYPE:
740
ADDRESS:5982 SHAY DEL PLACETELEPHONE:
(626) 827-9547
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 6DATE:
06/18/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator- Joanna GomezTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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2
3
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9
Facility staff are unable to communicate with residents due to language barrier.
INVESTIGATION FINDINGS:
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On June 18, 2025, at 9:20 AM Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit at the above facility. LPA Kim met with Administrator (ADMIN) Joanna Gomez and explained the purpose of the visit.

During today's visit, LPA Kim conducted a tour of the indoor and outdoor physical plant with ADMIN Gomez, and no concerns were observed. LPA Kim reviewed and obtained copies of the following records: Resident/Staff Rosters, Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, and other pertinent records for one (1) resident as well as the Personnel Report, Health Screening, training, and other pertinent records for two (2) staff. LPA Kim also conducted interviews for three (3) staff and two (2) residents.

Continued on LIC9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20250616162420
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: HILLS OF SHAY DEL, THE
FACILITY NUMBER: 306006118
VISIT DATE: 06/18/2025
NARRATIVE
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Allegation: Facility staff are unable to communicate with residents due to language barrier.

It is alleged a staff member does not speak English and are unable to communicate or understand resident.

Based on observations, LPA Kim observed staff speak English to the residents. When any resident requested water or going to the bathroom, staff promptly responded in English and assisted each of the residents.

Based on interviews conducted, three out of three staff and two out of six residents denied the allegation. Four out of six residents could not confirm or deny the allegation because they were not available to be interviewed at the time of visit. S1 stated all nighttime staff speak English and communicate with residents in English. S3 stated they understand and respond to the resident’s needs accordingly. All residents stated that all staff for all shifts speak English, and the staff understands and helps with all their needs.

Therefore, based on interviews and observation, LPA did not find sufficient evidence to support the allegation, Facility staff are unable to communicate with residents due to language barrier. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview was conducted and a copy of the report including the LIC811 were provided to Administrator Joanna Gomez.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5