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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006178
Report Date: 03/02/2026
Date Signed: 03/02/2026 04:58:56 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
02/27/2024 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240227123453
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: 6DATE:
03/02/2026
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Licensee Polly ValenciaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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7
8
9
Staff handles residents in a rough manner.
Staff spoke in an inappropriate manner to resident.
INVESTIGATION FINDINGS:
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5
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7
8
9
10
11
12
13
On March 2, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensee Polly Valencia was notified via telephone and later arrived to assist with the inspection.

During the course of the investigation, the Department interviewed residents, interviewed staff, reviewed and collected pertinent documents to this complaint. Regarding the allegation, staff handles residents in a rough manner, the following has been concluded: It was alleged that staff handle Resident #8 (R8) in a rough manner. The Department was unable to conduct an interview with R8 for this allegation, due to R8 passing away on July 7, 2024. The Department conducted seven resident interviews. Four out of the seven residents were unable to qualify for an interview. However, three out of the seven residents denied the allegation. The Department conducted seven staff interviews, including an interview with Licensee Polly Valencia. Seven out of the seven staff interviewed denied the allegation. CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
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 5
Control Number 22-AS-20240227123453
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: 03/02/2026
NARRATIVE
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However, the Department was able to obtain a video recording of an incident involving R8 and Licensee Polly Valencia, which was captured in R8’s bedroom. In the video recording, R8 appears to be adjusting herself to lay down on her bed. Licensee Polly Valencia is then seen wrapping both of her arms around R8 and tossing her down on the bed in an aggressive manner. R8 is then heard groining, which suggests this action may have caused her discomfort. At this point, R8's back is on the bed, however, her legs are still hanging on the side of the bed. Licensee Polly Valencia is then seen grabbing R8's legs with both arms, and tossing them onto the bed in an aggressive manner. R8 is seen saying something to Licensee Polly Valencia after this action, however, it is unclear of what was said.

Regarding the allegation, staff spoke in an inappropriate manner to resident, the following has been concluded: It was alleged that staff spoke in an inappropriate manner to R8. The Department was unable to conduct an interview with R8 for this allegation, due to R8 passing away on July 7, 2024. The Department conducted seven resident interviews. Four out of the seven residents were unable to qualify for an interview. However, three out of the seven residents denied the allegation. The Department conducted seven staff interviews, including an interview with Licensee Polly Valencia. Seven out of the seven staff interviewed denied the allegation. However, the Department was able to obtain a video recording of an incident involving R8 and Licensee Polly Valencia, which was captured in R8’s bedroom. In the video recording, Licensee Polly Valencia is seen speaking to R8 in an inappropriate manner multiple times. Licensee Polly Valencia is heard telling R8, "I am disgusted with you". Licensee Polly Valencia is heard telling R8, "I am absolutely disgusted with you". Licensee Polly Valencia is also heard telling R8, "Shame on you". Licensee Polly Valencia is heard making a fourth statement to R8, however, the video recording ends before the full statement is captured.

Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D page. An exit interview was conducted with Licensee Polly Valencia. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20240227123453
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: 03/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2026
Section Cited
CCR
87468.1(a)(1)
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7
87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not evidenced by:
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7
The Licensee stated that she will complete a statement and conduct an in service training with all staff regarding this regulation. The Licensee agreed to provide LPA the statement and proof of training via email or fax by POC date.
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Based on evidence gathered, the Licensee did not ensure Resident #8 was treated with dignity. LPA observed a video recording in which the Licensee spoke to R8 in an inappropriate manner. This poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
03/03/2026
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall ...:(3) ...be free from punishment, humiliation, intimidation, abuse...
This requirement was not evidenced by:
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The Licensee stated that she will complete a statement and conduct an in service training with all staff regarding this regulation. The Licensee agreed to provide LPA the statement and proof of training via email or fax by POC date.
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Based on evidence gathered, the Licensee did not ensure Resident #8 was free from intimidation and abuse. LPA observed a video recording in which the Licensee handled R8 in a rough manner. This poses an immediate health, safety, and 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: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC9099 (FAS) - (06/04)
Page: 3 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
02/27/2024 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240227123453

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: 6DATE:
03/02/2026
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Licensee Polly ValenciaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff video recorded residents without consent.
Staff forced resident to eat.
Staff hit resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On March 2, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Licensee Polly Valencia was notified via telephone and later arrived to assist with the inspection.

During the course of the investigation, the Department interviewed residents, interviewed staff, reviewed and collected pertinent documents to this complaint. Regarding the allegation, staff video recorded residents without consent, the following has been concluded: The Department conducted a tour of the interior and exterior portions of the facility. The Department did not observe cameras to be present in any of the resident bedrooms. The Department only observed cameras to be present in the common areas, such as the living room, dining room, kitchen, and resident hallways. The Department conducted seven resident interviews. Four out of the seven residents were unable to qualify for an interview. However, three out of the seven residents denied the allegation. CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
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-20240227123453
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: 03/02/2026
NARRATIVE
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The Department conducted seven staff interviews, including an interview with Licensee Polly Valencia. Seven out of the seven staff interviewed denied the allegation. The Department obtained a video recording from a camera that was placed in Resident #8 (R8) bedroom. The Department reviewed R8’s file. The Department observed that there was a consent form which authorized a camera to be placed in R8’s bedroom for safety reasons. The consent form was signed by R8’s Responsible Party and by Licensee Polly Valencia. However, the consent form was not signed by R8 and the Department was unable to conduct an interview with R8 for this allegation, due to R8 passing away on July 7, 2024.

Regarding the allegation, staff forced resident to eat, the following has been concluded: It was alleged that staff forced R8 to eat. The Department was unable to conduct an interview with R8 for this allegation, due to R8 passing away on July 7, 2024. The Department conducted seven resident interviews. Four out of the seven residents were unable to qualify for an interview. However, three out of the seven residents denied the allegation. The Department conducted seven staff interviews, including an interview with Licensee Polly Valencia. Seven out of the seven staff interviewed denied the allegation.

Regarding the allegation, staff hit resident, the following has been concluded: It was alleged that staff hit R8. The Department was unable to conduct an interview with R8 for this allegation, due to R8 passing away on July 7, 2024. The Department conducted seven resident interviews. Four out of the seven residents were unable to qualify for an interview. However, three out of the seven residents denied the allegation. The Department conducted seven staff interviews, including an interview with Licensee Polly Valencia. Seven out of the seven staff interviewed denied the allegation.

Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the three allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Licensee Polly Valencia and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5