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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006242
Report Date: 05/09/2025
Date Signed: 05/09/2025 12:11:07 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
02/19/2025 and conducted by Evaluator Samer Haddadin
COMPLAINT CONTROL NUMBER: 22-AS-20250219115828
FACILITY NAME:CAPRIANAFACILITY NUMBER:
306006242
ADMINISTRATOR:REYNOLDS, TONYAFACILITY TYPE:
741
ADDRESS:460 LA FLORESTA DRIVETELEPHONE:
(714) 985-5500
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:200CENSUS: 141DATE:
05/09/2025
UNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Tonya ReynoldsTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Due to lack of supervision, resident was left on the floor for an extended period of time after an unwitnessed fall
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint visit to present findings regarding the reported allegation mentioned above. Upon arrival, LPA Haddadin was greeted, granted access to the facility, and informed the staff of the visit's purpose. Executive Director (ED) Tonya Reynolds was later informed of the visit.
During the investigation, LPA Haddadin toured the facility, interviewed staff members, and reviewed all medical records pertaining to the alleged incident involving resident (R1).
The following allegation was investigated: "Due to a lack of supervision, the resident was left on the floor for an extended period following an unwitnessed fall."
The findings of the investigation are as follows: Regarding the allegation, it was reported that Resident (R1), a memory care resident, was discovered on the floor in their private restroom after an unknown duration, exhibiting a bump on their head. Subsequently, R1 was transported to UCI Medical Center for an assessment of their overall stability following the unwitnessed fall.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
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 2
Control Number 22-AS-20250219115828
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: CAPRIANA
FACILITY NUMBER: 306006242
VISIT DATE: 05/09/2025
NARRATIVE
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LPA Haddadin conducted four staff interviews, all of whom corroborated that the incident occurred. However, these interviews revealed that the facility conducts hourly rounds. R1 had recently concluded a family visit and had been returned to their room. The subsequent hourly round, during which R1 was found on the floor, took place 15 to 20 minutes after the visitation concluded.
Furthermore, LPA Haddadin reviewed R1's medical record, physician's report, admission record, and discharge paperwork from UCI Medical Center, where the resident was taken after the incident. According to the discharge paperwork from UCI, specifically on pages 9 and 10, the findings of the CT head scan revealed "Hemorrhage: None. Brain parenchyma: Moderate generalized volume loss...No herniation. No hydrocephalus...No acute calvarial fracture."
Therefore, based on the preponderance of evidence gathered through conducted interviews, medical record reviews, and all pertinent paperwork collected by LPA Haddadin, the allegation: "Due to a lack of supervision, the resident was left on the floor for an extended period following an unwitnessed fall," was found to be UNSUBSTANTIATED. This determination indicates that while the alleged incident may have occurred, or the concerns may be valid, there is not a preponderance of evidence to prove that the alleged violation took place.
No deficiencies were cited during today's visit. An exit interview was conducted with the ED, and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2