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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006342
Report Date: 07/30/2025
Date Signed: 08/22/2025 05:45:33 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
05/12/2025 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250512085342
FACILITY NAME:MARIGOLD BOARD AND CAREFACILITY NUMBER:
306006342
ADMINISTRATOR:TRANAE QUATICE GATLINFACILITY TYPE:
740
ADDRESS:8601 SAN ROMOLO WAYTELEPHONE:
(661) 236-6787
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: 4DATE:
07/30/2025
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Tranae GatlinTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Facility staff failed to properly report resident falls.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made unannounced follow up visit regarding the complaint allegation above. LPA explained the purpose for the visit upon entry.

Regarding the allegation above, 3 of 5 individuals interviewed confirmed R1 has fallen in their bedroom and while out of the facility. During interviews, S1 admitted that all R1’s falls were not reported to the department. S1 explained reports were not written for falls that happened outside of the facility while the resident was at church or for falls that occurred in R1’s bedroom. S1 explained R1 would slip/trip/fall while in their bedroom due to the room being cluttered with the residents own belongings. According to S1, R1 fell down to one knee and had to be assisted up by two caregivers on duty. S1 explained there was no incident report submitted after that fall when R1 went down to one knee. Further, S1 confirmed R1 fell in their room and hit another residents walker causing some discoloration.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
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-20250512085342
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: MARIGOLD BOARD AND CARE
FACILITY NUMBER: 306006342
VISIT DATE: 07/30/2025
NARRATIVE
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According to S1, caregivers assess the residents for injuries after falls, S1 mentioned they encourage all their residents to use their walker when ambulating, and they advise residents to keep walkways in their room free of clutter.

Based on the evidence gathered through interview confirmation and document review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22.

An exit interview was conducted and a copy of this report and appeal right were provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250512085342
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: MARIGOLD BOARD AND CARE
FACILITY NUMBER: 306006342
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2025
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements
(a) Each licensee shall furnish...reports as the Department may require, including, but not limited to...
(1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified... below. This report shall include the resident’s name, age...disposition of the case. This requirement is not being met as evidenced by:
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Administrator Gatlin will read and review the regulation section on reporting requirements and email LPA Haley a signed statement of acknowledgement and understanding by 4:00pm on the POC due date.
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Administrator Gatlin confirmed no incident reports were completed and submitted to the department when R1 fell while outside of the facility or when R1 fell to their knee while in their room.
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3