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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006295
Report Date: 05/06/2025
Date Signed: 06/16/2025 01:45:37 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
04/29/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20250429140446
FACILITY NAME:SENIOR FAMILY HOME 1FACILITY NUMBER:
306006295
ADMINISTRATOR:AGUSTIN, REYNALDOFACILITY TYPE:
740
ADDRESS:3148 W ROME AVENUETELEPHONE:
(714) 600-6195
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 6DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Reynaldo "Ahl" AugustinTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff not providing resident with arrangements to meet health needs.
INVESTIGATION FINDINGS:
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LIcensing Program Analyst (LPA) made an unannounced visit to investigate a complaint received in our Regional Office. LPA was greeted and granted entry by care staff. LPA met with Administrator, Reynaldo "Ahl" Augustin and explained the purpose of the visit.

LPA requested files for Resident #1 (R1) which include: Identification and Emergency Information, Physician's Report,Preappraisal Information and Appraisal Needs and Services Plan and Admissions Agreement. LPA interviewed R1 regarding care provided and asked resident if arrangements to meet R1's health needs are being met. R1 showed LPA the health issue requested and LPA observed this was not met. R1 allowed LPA to take photographs for documentation. LPA reviewed LIC 602A which states resident is unable to groom self. Administrator also admitted he did not schedule podiatry appointment.

(Continued on LIC 9099-C)
****THIS IS AN AMENDED REPORT****
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
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-20250429140446
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 FAMILY HOME 1
FACILITY NUMBER: 306006295
VISIT DATE: 05/06/2025
NARRATIVE
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(Continued from LIC 9099)

Based on LPA's observations and record review, the preponderance of evidence has been met, therefore the allegation of: Staff not providing resident with arrangements to meet health needs is Substantiated. The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Reynaldo Augustin, Administrator 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: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250429140446
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 FAMILY HOME 1
FACILITY NUMBER: 306006295
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2025
Section Cited
CCR
87465(a)(1)
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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. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care...by:(1) The licensee shall arrange, or assist in
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The Plan of Correction (POC) is that Administrator shall provide LPA with scheduled appointment details for R1 by 5pm on May 7, 2025. LPA also requests follow-up after the appointment with documentation that health need was met.
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arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not being met as evidenced by: Resident #1 showed LPA physical health issue which poses an immediate health and safety risk for the person 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: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3