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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006360
Report Date: 12/30/2025
Date Signed: 12/30/2025 03:02:05 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
07/10/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240710083946
FACILITY NAME:WATERMARK LAGUNA NIGUELFACILITY NUMBER:
306006360
ADMINISTRATOR:THARP, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:27762 FORBES ROADTELEPHONE:
(520) 797-4000
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:135CENSUS: 61DATE:
12/30/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Johnny OrtizTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not ensure that resident took medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings for the complaint investigation into the allegation listed above. LPA met with Executive Director Johnny Ortiz and explained the reason for the visit. The investigation into the allegation, staff did not ensure that the resident took medication as prescribed revealed the following. It was reported that Resident 1 (R1) did not take their prescribed medication for 12 days. A review records shows R1 moved into the facility on February 28, 2024 and moved out on April 2, 2024. A review of R1's Medication Administration Record (MAR) for February, March and April, 2024 shows R1 was prescribed 10 medications including 2 PRNs. R1 missed routine medications on March 4, because they were out of the facility with their family. On March 8, 2024 R1 missed routine medications, Ezetimbe, Losartan potassium F/C, Quetiapine Fumarate and Isosorbide Mononitrate ER for their 9:00 am medication pass. Staff reported that after any missed dose the physician and responsible party are notified. Based on the evidence gathered, the preponderance of evidence standard has been met, therefore the allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
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 5
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
07/10/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240710083946

FACILITY NAME:WATERMARK LAGUNA NIGUELFACILITY NUMBER:
306006360
ADMINISTRATOR:THARP, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:27762 FORBES ROADTELEPHONE:
(520) 797-4000
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:135CENSUS: 61DATE:
12/30/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Johnny OrtizTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Staff did not ensure that resident's meals were consumed
Staff did not protect resident from being exploited
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings for the complaint investigation into the allegations listed above. LPA met with Executive Director Johnny Ortiz and explained the reason for the visit. The investigation into the allegation, staff did not ensure that resident's meals were consumed revealed the following. It was reported that Resident 1 (R1) did not eat for 10 days, no other details were provided. A review of resident records shows that on March 13, 2024 that R1 refused to eat breakfast and lunch and on March 27, 2024 R1 refused to eat breakfast. 3 out of 3 caregivers interviewed reported that R1 usually eats all of her meals except for the dates listed above. R1 moved out of the facility and subsequently passed away and was not interviewed. R1's responsible party never responded to the LPA's request to be interviewed. The former Administrator and Resident Care Director reported they had no knowledge of R1 not eating their meals. None of the evidence gathered supports the allegation, therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20240710083946
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: WATERMARK LAGUNA NIGUEL
FACILITY NUMBER: 306006360
VISIT DATE: 12/30/2025
NARRATIVE
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The investigation into the allegation, staff did not protect resident from being exploited, revealed the following. It was reported that the facility allowed Resident 1 (R1) to be financially exploited and that the former Administrator assisted in financially exploiting R1. No other details were provided. The former Administrator denied the allegation. R1 was moved into the facility on February 28, 2024 by their responsible party and moved out April 2, 2024. R1 has been diagnosed with Dementia. R1 moved out of the facility and subsequently passed away and was not interviewed. A record review shows the Power of Attorney paperwork for R1 is incomplete and is therefore not valid. The former Administrator reported they never received completed Power of Attorney paperwork from the responsible party or any other family member. It was reported that the former Administrator allowed a family member to visit R1 against the wishes of the responsible party and this led to the financial exploitation of R1. R1's family member would not respond to the LPA's request for an interview and subsequently passed away. The former Administrator reported that they informed R1's responsible party that they could not deny visitation without a court order or restraining order. R1's responsible party did not respond to the LPA's request for an interview. 3 out of 3 staff members interviewed had no knowledge of R1 being financially exploited. None of the evidence gathered supports the allegation, therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20240710083946
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: WATERMARK LAGUNA NIGUEL
FACILITY NUMBER: 306006360
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2026
Section Cited
CCR
87468.1(a)(16)
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(16) To receive or reject medical care or other services. This requirement was not met as evidenced by on March 8, 2024, R1 missed receiving 4 routine medications on the morning medication pass at 9:00am.
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Licensee agrees to train medication staff on CCR 87468.1 and on facility medication administration procedures. Facility to forward proof of training to LPA by POC due date.
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This poses a potential health and safety risk to residents 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: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 22-AS-20240710083946
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: WATERMARK LAGUNA NIGUEL
FACILITY NUMBER: 306006360
VISIT DATE: 12/30/2025
NARRATIVE
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Violations are being cited per California Code of Regulations, Title 22 division 6. An exit interview was conducted and a copy of the report and appeals rights was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5