306006118-1-15-2026-22-AS-APAO-DQJQGS-20260121110958

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006118
Report Date: 01/15/2026
Date Signed: 01/15/2026 10:50:25 AM

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
01/09/2026 and conducted by Evaluator Edward Kim

COMPLAINT CONTROL NUMBER: 22-AS-20260109143610

FACILITY NAME:	HILLS OF SHAY DEL, THE		FACILITY NUMBER:	306006118
ADMINISTRATOR:	NEPOMUCENO, MARICEL		FACILITY TYPE:	740
ADDRESS:	5982 SHAY DEL PLACE		TELEPHONE:	(626) 827-9547
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 3	DATE:	01/15/2026
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Caregiver- Hannah Jose		TIME COMPLETED:	11:00 AM

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 15, 2026, at 8:00 AM Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA Kim spoke with Licensee (LI) Maricel Nepomuceno over the phone who stated that they could not attend today’s visit. LI Nepomuceno stated that caregiver (CG) Hannah Jose could sign on behalf of the facility.

The investigation consisted of the following. LPA Kim toured the facility. LPA Kim reviewed and obtained copies of the following records for two Residents: 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 conducted interviews with five staff, one witness, and one resident

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: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

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 4

Control Number 22-AS-20260109143610

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: 01/15/2026

NARRATIVE

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Allegation: Staff did not provide authorized representative with a refund after resident passed away.

It is alleged the staff would refund part of the money, but the Resident #1 (R1) responsible party never received the refund. R1 moved into the facility on October 1, 2025 and passed away on October 5, 2025. The resident’s belongings were removed out of the facility in October.

Based on interviews conducted, five out of five staff and one out of one witness corroborated the allegation. One out of one resident could not confirm or deny the allegation. All staff stated that R1 lived in Room 1 and passed away on October 5, 2025. All staff stated R1’s personal belongings were removed on October 6, 2025. All staff stated they heard that the facility did not provide a refund to R1 in a timely manner. S2 stated that the monthly amount for R1 was $7220. S2 stated the admission agreement stated the monthly amount for $7200 and they did not update the admission agreement for the $20 additional charge for DVR. S2 stated that the facility received and deposited a $3500 but did not deposit a check for the amount of $3720 and voided it. One witness also stated that the facility received an amount of $3500 and the facility did not deposit a check for the amount of $3720.

Based on record review, the Admission Agreement dated October 1, 2025, stated R1 was admitted to the facility on October 1, 2025. The additional $20 charge for DVR was not updated on the admission agreement. A text message dated October 4, 2025, stated the DVR will be additional $20 per month. On page 5 of the Admission Agreement, stated on page 5 that the admission agreement is terminated on the date of the resident’s death and refund schedule will be prorated The admission agreement stated the responsible party will not be responsible for any charges after the resident’s date of death. A text message dated on October 6, 2025, at 12:39 PM stated that R1’s belongings were picked up and any remaining items will be removed that same day. A text message dated on October 13, 2025, at 2:39 PM, shows a check dated October 2, 2025, for the amount of $3720 marked “Void.”

Based on observation, LPA verified that R1 no longer resides at the facility via the Resident Roster dated December 10, 2025. R1 passed away on October 5, 2025, and all of their belongings were removed from Room 1.

Continued on LIC9099C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260109143610

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: 01/15/2026

NARRATIVE

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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. A civil penalty was assessed for a repeated deficiency.

Exit interview was conducted, and a copy of the report, LIC9099D, LIC811s, a civil penalty, and the appeal rights were provided to Caregiver Hannah Jose and a copy of the report will be mailed to the corporate address.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 22-AS-20260109143610

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: 01/15/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/23/2026 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	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	1 2 3 4 5 6 7	Licensee states they will pay a refund of $2335.48 to R1’s Responsible Party who paid the October payment and will send proof of payment to CCLD via email to Edward.kim@dss.ca.gov by POC due date January 23, 2026.
	8 9 10 11 12 13 14	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 October. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14	A Civil Penalty was assessed for a repeated violation for deficiency on HSC 1569.652(c) within the year.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC9099 (FAS) - (06/04)

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