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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006295
Report Date: 06/16/2025
Date Signed: 06/16/2025 04:13:29 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
06/13/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20250613094107
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:
06/16/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ahl Augustin, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility does not assist residents with their daily needs.
Facility does not accord residents with dignity and respect.
Facility does not have night supervision.
Residents are not afforded healthy and safe accommodations.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct a complaint investigation regarding the above allegations. LPA met with Administrator (AD) Ahl Augustin and explained the purpose of the visit.

LPA reviewed and obtained copies of Resident #1 (R1's): Identification and Emergency Form, Physician's Report, Preplacement Appraisal, Appraisal Needs and Services Plan, and a signed letter dated June 16, 2025 regarding new facility for placement to meet R1's health needs. AD also forwarded email with Care Coordination Agency (CCA) regarding Assisted Living Waiver (ALW) placement. LPA interviewed three of three staff, one outside witness and four of four residents.

LPA asked both residents and staff if water is restricted after 6pm. Three of four residents confirmed water is always accessible. Three of three staff and one witness confirmed residents have access to water at all times and that one resident even is able to have snacks in the middle of the night.
(Continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
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-20250613094107
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: 06/16/2025
NARRATIVE
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(Continued from LIC 9099)
Three of four residents confirmed that the two day caregivers always accommodate their needs. In the evening, there is one staff member and there is always staff in the facility at all times. If a female needs changing, in the middle of the night, the AD, who is the night staff member five days per week, will call and pay a female caregiver who lives nearby to change the female soiled diaper. This has only occurred recently and had not been an issue until a resident's health needs changed. The allegation that there are no staff, in the evening, is false. One of four residents did not confirm, nor deny allegation and stated they, "were fine."

LPA spoke with residents to see if they were afforded dignity and respect in their interactions with facility staff. Three of four residents strongly agreed that staff are available for their needs. Staff do not yell at them, although one staff member is hard of hearing and speaks louder. LPA asked if residents' toileting and hygiene needs were being met and three of four residents confirmed they receive assistance, when needed. One of four residents did not confirm or deny allegation but this resident receives daily sponge baths and refuses to take showers due to weakness from a current health condition. Three of three staff confirmed showers are offered to one resident but that the resident states they are, "weak and dizzy" and refuses to shower.

Residents were asked if they had safe and sanitary physical accommodations. Three of four residents felt safe and that the facility was clean. LPA did not observe any odors upon touring the facility and checking on the health and safety of the other residents. Resident #2 (R2) stated roommate, R1, requires a higher level of care and demands to have their needs met before others. The example given was that, if R1's appointment gets rescheduled, R1 feels R1's appointment is the priority and that the other five residents' appointments should be rescheduled or canceled.

LPA spoke with the outside witness who confirmed that a meeting was held with R1 and AD and that the facility is doing all that they can to accommodate the resident's needs. The witness stated R1 is not consistent in their requests and does not follow things through.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations that: Facility does not assist residents with their daily needs, Facility does not accord residents with dignity and respect, Facility does not have night supervision and Residents are not afforded
(Continued on LIC 9099-C1)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250613094107
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: 06/16/2025
NARRATIVE
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(Continued from LIC 9099-C)

healthy and safe accommodations Based on LPA file review, observations and interviews the allegations are Unsubstantiated.

An exit interview was conducted with Administrator, Ahl Augustin, and a copy of this report and LIC 811, Confidential Names, were provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3