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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006118
Report Date: 01/05/2026
Date Signed: 01/05/2026 01:44:41 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
12/29/2025 and conducted by Evaluator Edward Kim
COMPLAINT CONTROL NUMBER: 22-AS-20251229115133
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: DATE:
01/05/2026
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator- Joanna GomezTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not provide authorized representative with a refund after resident passed away.
INVESTIGATION FINDINGS:
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On January 5, 2026, at 8:30 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 for Resident #1 (R1): Admission Agreement, Identification and Emergency Information, Physician's Report, Appraisal Needs and Services Plans, and other pertinent records. LPA reviewed and obtained the Personnel Record, Resident Roster, and other pertinent records. LPA Kim also conducted three (3) staff interview.

The investigation revealed the following:
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026
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-20251229115133
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: 01/05/2026
NARRATIVE
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Allegation: Staff did not provide authorized representative with a refund after resident passed away.
It is alleged the facility agreed to pay a refund, but the facility has not paid a refund for R1's responsible party after R1's death on September 25, 2025, and the removal of R1 personal belongings.

Based on interviews conducted, three out of three staff corroborated the allegation. All staff stated that R1 lived in Room 3 and passed away on September 25, 2025. S1 stated R1’s personal belongings were removed on September 25, 2025. S2 and S3 stated that R1’s personal belongings were removed on September 26, 2025. S1 stated they were informed that a refund was not provided and then proceeded to let their supervisor know the situation. S2 and S3 both stated they heard that the facility did not provide a refund to R1.

Based on record review, the Admission Agreement dated May 27, 2025, stated R1 was admitted to the facility on May 27, 2025. On page 5 of the Admission Agreement, it stated that anything after 14 days is refundable and will be based on a prorated amount. It is also stated on page 5 that the admission agreement is terminated on the date of the resident’s death and refund schedule remains as mentioned in the admission agreement. The admission agreement stated the responsible party will not be responsible for any charges after the resident’s date of death. The visitor’s log dated on September 25, 2025, lists three visitors on the day R1 passed. There are no future dates of anyone visiting for R1 to pick up their belongings on September 26, 2025, or any future date. An incident report dated October 3, 2025, stated that family and hospice were present at the time R1 passed away.

Based on observation, LPA verified that R1 no longer resides at the facility and all of their belongings were removed.

Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff did not provide authorized representative with a refund after resident passed away 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: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20251229115133
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: 01/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2026
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 pay a refund of $1116.67 to R1’s Responsible Party who paid the September payment and the licensee will send proof of payment to CCLD via email to Edward.kim@dss.ca.gov by POC due date January 14, 2026.
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Based on record review, interview, and observation, the licensee did not comply with the section cited above. A refund was not issued to R1’s responsible party who paid for the month of September. This poses a potential health and safety risk to persons in care. ***This is an amended report***
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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: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026
LIC9099 (FAS) - (06/04)
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