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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006295
Report Date: 04/22/2026
Date Signed: 04/22/2026 03:48:37 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
03/26/2026 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20260326111843
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: 5DATE:
04/22/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Ahl Agustin, AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident sustained multiple bruises while in care
Staff do not ensure resident receives adequate care with personal grooming assistance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint that was received in the Regional Office. LPA was greeted and granted entry by Staff #1 (S1) at 8am. The facility currently has five residents in care.

LPA obtained the following documents for Resident #1 (R1) on March 26, 2026: Identification and Emergency Information, Medical Assessment dated January 23, 2026; Appraisal Needs and Services Plan and Preplacement Appraisal Information dated January 23,2026; Skilled Nursing Facility Discharge Summary; Capacity Assessment Declaration – Probate Conservatorship dated January 9, 2026, Admissions Agreement and Addendum and Admission to Hospice notification.

Resident #1 (R1) was admitted to the facility on January 23, 2026, from a Skilled Nursing Facility (SNF).
(Continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
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-20260326111843
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: 04/22/2026
NARRATIVE
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(Continued from LIC 9099)

In December 2025, prior to being admitted to the facility, Resident #1 (R1) had a fall in the home and was diagnosed with a right intertrochanteric femur fracture that required surgery which was completed on December 9, 2025. R1 was then admitted to a Skilled Nursing Facility (SNF) on December 12, 2025, and was released to the this facility on January 23, 2026. Per Medical Assessment dated 1/23/2026 R1’s requires orthopedic aftercare and is non-ambulatory. Appraisal Needs and Services Plan and Pre-Appraisal dated 1/23/2026 state R1 has major neurocognitive disorder. On January 9, 2026, a Capacity Assessment was signed by the physician that R1 has major neurocognitive disorder and agitation.

It was alleged that Resident sustained multiple bruises while in care. LPA reviewed Medical Assessment dated 1/23/2026, Appraisal Needs and Services Plan dated 1/23/2026 Preplacement Appraisal dated 1/23/2026 and the Skilled Nursing Facility Discharge Summary dated 1/23/2026. Documents reviewed revealed no documentation of bruises on Resident #1 (R1). LPA interviewed three of three staff members who all stated R1 came to the facility with various stages of bruising due to the orthopedic surgery. Three of three staff denied the allegation that bruises occurred while in facility care. Two of three witnesses interviewed also stated R1 had bruises prior to coming to the facility and was prone to bruising and denied that the facility caused the bruises. One of three witnesses could not confirm, nor deny the allegation. Resident #1 was interviewed and was asked if bruises occurred while in care. R1 answered No. Two other residents were asked about care provided at the facility and two of two residents stated they receive good care from the staff.

LPA also investigated the allegation that Staff do not ensure resident receives adequate care with personal grooming assistance. R1 has a history of psychosis and refusing medications or personal assistance. Two of three witnesses stated that while R1 had a history of not changing, or showering prior to moving into the facility. Two of three witnesses stated that they do not believe the facility is not offering these services but feel that R1 refuses these services. One of three witnesses could not confirm nor deny the allegation but did state R1 would be a challenging patient but hoped with time that this may change. LPA interviewed three of three staff who all denied the allegation. Staff reported they sponge bathe R1 daily and clean fingernails with wipes daily. LPA interviewed R1 to ask if they were happy with services being provided, which included personal care and R1 answered Yes.

(Continued on LIC 9099-C1)

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

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260326111843
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: 04/22/2026
NARRATIVE
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(Continued from LIC 9099-C)

When asked if there were any problems, R1 answered No. LPA observed R1 was clean and dressed, fingernails were clean and feet were covered with socks. The facility does not maintain a log of personal grooming assistance for residents.

Based on LPA’s record review, interviews and observations the allegations that Resident sustained multiple bruises while in care and Staff do not ensure resident receives adequate care with personal grooming assistance is Unsubstantiated meaning the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator (AD) Ahl Agustin and a copy of this report and LIC 811 were provided to the facility.

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

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3