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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006253
Report Date: 12/04/2025
Date Signed: 12/04/2025 11:02:31 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
12/03/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20251203112100
FACILITY NAME:SENIOR'S RETREAT OF BREA, INC., THEFACILITY NUMBER:
306006253
ADMINISTRATOR:SMITH, LORNAFACILITY TYPE:
740
ADDRESS:311 GUAVA PLTELEPHONE:
(562) 746-7899
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 2DATE:
12/04/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Lorna Smith, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff is physically forcing resident to take medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Lorna Smith and explained the purpose of the visit.

It is alleged that Staff is physically forcing resident to take medication. Resident #1 (R1) recently moved into the residence on November 28, 2025 after a week's stay in the hospital. LPA reviewed hospital discharge records and Medical Assessment dated 11/28/2025. R1 has multiple diagnoses; which include: bipolar disorder, paranoid schizophrenia and psychosis. Resident is alert, non-ambulatory and uses a motorized wheelchair. LPA requested and reviewed a Medication Administration Record for R1.

LPA interviewed two of two residents, two of two staff members and three of three witnesses. Based on interviews conducted, it is confirmed that the resident was physically forced to take medications.
(Continued on LIC 809-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
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 3
Control Number 22-AS-20251203112100
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: SENIOR'S RETREAT OF BREA, INC., THE
FACILITY NUMBER: 306006253
VISIT DATE: 12/04/2025
NARRATIVE
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(Continued from LIC 809)

Based on LPA's observations, interviews conducted and record review, the preponderance of evidence standard has been met. Therefore the allegation that Staff is physically forcing resident to take medication is Substantiated and a deficiency will be cited per Title 22, California Code of Regulations.

An exit interview was conducted with Administrator, Lorna Smith, and a copy of this report, LIC 9099-D, LIC 811 and Appeal Rights were provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20251203112100
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: SENIOR'S RETREAT OF BREA, INC., THE
FACILITY NUMBER: 306006253
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2025
Section Cited
CCR
87465(a)(5)(D)
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87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility... :(5) Facility staff...may assist persons with self-administration..: (D) Assistance with self-administration does not include forcing a resident to take medication, ... or
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Administrator (AD) will provide LPA with a written Memo of Understanding regarding regulations 87465 and 87468 and will email signed documenation by POC due date.
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otherwise infringing upon a resident's right to refuse to take a medication. This requirement is not met as evidenced by: Based on LPA's interviews and record review this was not met for R1 which poses an immediate health and safety risk to persons in care
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Type A
12/05/2025
Section Cited
CCR
87608(a)(3)
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87608 Postural Supports. (a) Based on the individual's preadmission appraisal... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record... This requirement was
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AD will obtain documentation for postural supports at a medical appointment on 12/04/25 with any additional documentation and will email physician's orders for bed rails to LPA by 12/05/2025.
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not met as evidenced by: Based on LPA observations, interview and record review this was not met in one of one residents which poses an immediate health and safety 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: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3