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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006242
Report Date: 04/28/2026
Date Signed: 04/28/2026 10:13:37 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
03/16/2026 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20260316151041
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: 142DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Tonya Reynolds, Executive DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility did not provide requested care log documentation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint received in the Regional Office. LPA was greeted and granted entry by the Concierge at 9:45am. LPA met with Executive Director (ED) Tonya Reynolds and explained the purpose of the visit.

LPA obtained the following documents for Resident #1 (R1): Medication Administration Record for February 2026; Charting notes from February 3-26, 2026; Physician's orders dated February 11, 14 and 17, 2026; Bowel protocol for February 2026; Staff Assignments by Month for March 2026; and Shift Reports for February 2026. LPA reviewed email communications regarding R1 with Responsible Parties as well as Resident #1 (R1)’s Durable Power of Attorney for Assets and Resident Services Agreement. LPA also reviewed Unusual Incident Reports submitted to the Department for incidents that occurred on February 11th and 25th, 2026.

(Cont9inued on LIC 9099)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
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-20260316151041
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: 04/28/2026
NARRATIVE
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(Continued from LIC 9099)

It was alleged that Facility did not provide requested care log documentation. R1’s Durable Power of Attorney (DPOA) requested Activities of Daily Living (ADL) care logs regarding Resident #1 (R1) on February 11, 2026 via email. Three of three staff interviewed stated they responded to Power of Attorney (POA) and provided documentation requested. Additional documentation was requested by the POA but the February ADL care log was determined to be an internal document by the facility and was not provided. ED stated the information on the ADL care logs were transcribed into the alert charting notes; which the POA was given. The original care logs were not provided.

Department review of the requested documents determined that the ADL care logs are documentation of R1’s ADL’s which could impact the resident's ability to function or for needed services required. The requested documentation was not provided within two business days to the POA. Based on document review and interviews the preponderance of the evidence standard has been met and the allegation that Facility did not provide requested care log documentation is Substantiated.

An exit interview was conducted with Executive Director (ED) Tonya Reynolds and a copy of this report was given to the facility along with a copy of the LIC 9099-D and Appeal Rights.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260316151041
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2026
Section Cited
CCR
87468.2(a)(19)
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Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilties, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) to have
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ED will in-service administrative team on resident rights regarding providing appropriate resident documentation to POA by POC due date.
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prompt access to review all of their records... Photocopied records shall be provided within two (2) business days...This requirement is not met as evidenced by: Based on LPA interviews, the requested records were not received within 2 days which poses a potential risk for 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: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3