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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006369
Report Date: 02/20/2025
Date Signed: 02/20/2025 12:34:48 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
02/20/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20250220103503
FACILITY NAME:HILLS OF GOWDY, THEFACILITY NUMBER:
306006369
ADMINISTRATOR:SO, BRYANTFACILITY TYPE:
740
ADDRESS:23981 GOWDY AVENUETELEPHONE:
(714) 430-7672
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 4DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Carla Ward, Administrator (AD)TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff is not providing a refund upon resident’s death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office on February 13, 2025. LPA was greeted and granted entry by staff and met with Administrator (AD) Carla Ward and explained the purpose of the visit.

LPA requested Register of Facility Residents for facility #306006369, which was a Change of Ownership (CHOW) effective October 29, 2024. The resident resided at this facility and passed away on December 13, 2024 and personal property and effects were also removed on December 13, 2024.

Documentation obtained include: ID and Emergency Information, Admissions Agreement which included the facility's refund policy and copies of the check written on February 13, 2025 by the Licensee company with the letter sent to Resident's Responsible Party; also dated February 13, 2025.

(Continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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-20250220103503
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: HILLS OF GOWDY, THE
FACILITY NUMBER: 306006369
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
HSC
1569.652(c)
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 (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual...responsible for the fees... within 15 days after the personal property is removed.
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Licensee and Administrator to provide LPA with training inservice or letter of understanding of the CCR Title 22 and HSC regulations regarding refunds for residents.
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This requirement was not met as evidenced by: Based on LPA record review and interviews, one of one resident did not receive a timely refund. This poses a potential health and safety risk for residents in care. ***This is an amended report***
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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: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250220103503
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: HILLS OF GOWDY, THE
FACILITY NUMBER: 306006369
VISIT DATE: 02/20/2025
NARRATIVE
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(Continued from LIC 9099)

Based on LPA's observations, record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. The following deficiency is being cited per Health and Safety Code 1569.652(c) on the LIC 9099-D.

An exit interview was conducted with Carla Ward, Administrator (AD) and a copy of this report was given to the facility along with Appeal Rights.


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

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3