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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006178
Report Date: 12/17/2025
Date Signed: 12/17/2025 02:52:21 PM

Unsubstantiated


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
04/16/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240416125427
FACILITY NAME:POLLY'S PLACEFACILITY NUMBER:
306006178
ADMINISTRATOR:VALENCIA, POLLYFACILITY TYPE:
740
ADDRESS:2143 W. FIR AVE.TELEPHONE:
(949) 412-2579
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 5DATE:
12/17/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Polly ValenciaTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Facility failed to ensure a resident's visitation rights
Facility staff failed to report a fall incident to a resident's reporting party in a timely manner
Facility staff failed to notify a resident's responsible party of a change in condition requiring an admission onto hospice care
Facility staff did not provide a responsible party with a list of the prescribed medication for a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Administrator Polly Valencia and explained the reason for the visit.

The investigation into the allegation, facility failed to ensure resident's visitation rights, revealed the following. It was reported that on two occasions facility staff told Resident 1's (R1) family members not to visit because R1 was asleep or was overwhelmed. The Administrator reported they never told any possible visitor not to visit. 4 out of 4 staff interviewed reported they have never told anyone not to visit a resident. No specific details were provided as to who informed possible visitors they could not visit or the dates that it occurred. LPA attempted to contact R1's responsible party but never received a response so they were not interviewed. R1's whereabouts are unknown so they could not be interviewed. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
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 6
Control Number 22-AS-20240416125427
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: POLLY'S PLACE
FACILITY NUMBER: 306006178
VISIT DATE: 12/17/2025
NARRATIVE
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The investigation into the allegation, facility staff failed to report a fall incident to a resident's reporting party in a timely manner, revealed the following. It was reported that in September 2023, R1 suffered a fall and the responsible party was not notified in a timely manner. No specific date was provided for R1's fall. The Administrator reported that R1 did have a fall in September 2023 but could not remember the exact date. Staff 1 reported that R1 started to fall out of their wheelchair and Staff 1 broke their fall but R1 still bumped their head on the ground. At that time R1's hospice nurse was present and assessed R1. R1's hospice nurse assessed R1 and determined R1 did not need emergency services. First aid was applied and R1 was taken to her room. R1' hospice nurse verified this information. The Administrator reported they contacted R1's responsible party and reported the incident. LPA attempted to contact R1's responsible party but never received a response so they were not interviewed. R1's whereabouts are unknown so they could not be interviewed. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.

The investigation into the allegation, facility staff failed to notify a resident's responsible party of a change in condition requiring an admission onto hospice care, revealed the following. Resident 1 (R1) moved into the facility May 15, 2023 and moved out November 30, 2023. A review of records shows R1 was put on hospice on September 9, 2023. The Administrator reported that R1 appeared to be losing weight and wanted R1 to be evaluated by hospice. The Administrator reported that R1 agreed. The Administrator reported that they informed the responsible party and they agreed. R1 was assessed and hospice was approved. R1 was admitted to hospice for unspecified protein/calorie malnutrition. The Administrator reported that the responsible party was notified and kept informed of all of R1's changes. LPA attempted to contact R1's responsible party but never received a response so they were not interviewed. R1's whereabouts are unknown so they could not be interviewed. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.

The investigation into the allegation, facility staff did not provide a responsible party with a list of the prescribed medication for a resident, revealed the following. It was reported that after R1 moved out the responsible party requested a list of medications for R1. It was reported that the facility was taking R1 to medical appointments without notifying the responsible party. The Administrator reported that R1's appointments were at the facility and the responsible party was notified about each appointment.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
04/16/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240416125427

FACILITY NAME:POLLY'S PLACEFACILITY NUMBER:
306006178
ADMINISTRATOR:VALENCIA, POLLYFACILITY TYPE:
740
ADDRESS:2143 W. FIR AVE.TELEPHONE:
(949) 412-2579
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 5DATE:
12/17/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Polly ValenciaTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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2
3
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9
Facility staff failed to report a fall incident to the Department
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met with Administrator Polly Valencia and explained the reason for the visit.

The investigation into the allegation, facility staff failed to report a fall incident to the Department, revealed the following. It was reported that Resident 1 (R1) suffered a fall and it was not reported to the Department (Community Care Licensing). The Administrator and Staff 1 verified R1 suffered a fall in September 2023 but did not remember the exact date. The Administrator reported that after the fall R1's hospice nurse assessed R1 and emergency services were not required. The Administrator reported that first aid was applied and there were no further issues with R1. The Administrator verified that no incident report was sent to the Department. Based on the evidence gathered the preponderance of evidence standard has been met,
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20240416125427
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: POLLY'S PLACE
FACILITY NUMBER: 306006178
VISIT DATE: 12/17/2025
NARRATIVE
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therefore the allegation is substantiated. Deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20240416125427
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: POLLY'S PLACE
FACILITY NUMBER: 306006178
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/26/2025
Section Cited
CCR
87211(a)(1)
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A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...This requirement was not met as evidenced by
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Licensee agrees to sign a statement of understanding for CCR 87211 and to train staff on CCR 87211. Licensee to submit proof to LPA by the POC due date.
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The facility verified R1 suffered a fall in September 2023 but did not report it to the Department, this poses a potential health and safety risk to residents 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: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20240416125427
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: POLLY'S PLACE
FACILITY NUMBER: 306006178
VISIT DATE: 12/17/2025
NARRATIVE
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The Administrator reported that any issues with medication should have been communicated with the physician because the facility only administers medications as prescribed and doesn't decide what medications are prescribed. The Administrator reported that the responsible party was provided with R1's medications and a list of their medications when R1 moved out. LPA attempted to contact R1's responsible party but never received a response so they were not interviewed. R1's whereabouts are unknown so they could not be interviewed. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur.

An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6