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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006485
Report Date: 04/23/2025
Date Signed: 04/23/2025 10:44:53 AM

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
04/16/2025 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250416120858
FACILITY NAME:HILLS OF VIA DEL SOL, THEFACILITY NUMBER:
306006485
ADMINISTRATOR:CUYSON, ELEAZARFACILITY TYPE:
740
ADDRESS:26462 VIA DEL SOLTELEPHONE:
(714) 430-7672
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
04/23/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Allen Medina- Chief Executive Officer
Keack Vongphakdy- Director of Business/AttorneyAllen 		TIME COMPLETED:
11:05 PM
ALLEGATION(S):
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Facility did not refund resident's monthly fees after resident's death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of delivering the findings into the above allegation. LPA was greeted and granted entry by Administrator (Admin) Eleazar Cuyson after stating the purpose of the visit. During the course of the investigation, LPA interviewed two staff and obtained pertinent records pertaining to Resident #1 (R1) such as the Resident Roster, Personnel Report Summary, Face Sheet, Physician's Report, Admission Agreement, Personal Rights of Residents, a photograph of the check, and the Death Report.

The investigation revealed the following:

It is alleged that the facility did not refund the resident's monthly fees after the resident's death. Per page 4 of the admission agreement signed and dated on March 24, 2024, the contract indicates that the "admission agreement is automatically terminated on the date of the resident's death." R1 passed away on January 9, 2025 per Death Report dated January 11, 2025.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
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-20250416120858
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 VIA DEL SOL, THE
FACILITY NUMBER: 306006485
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2025
Section Cited
CCR
87507(5)(A)
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87507 Admission Agreements
(5) Refund conditions. (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652.

This requirement was not met as evidenced by:
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Licensee to provide proof that the amount issued was withdrawn and to submit an Acknowledgement of Understanding of the said deficiency to LPA via email by POC due date.
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Based on interviews and record review, facility did not issue a refund after R1's passing for 1/10-31/25 in which poses a personal rights risk to persons 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250416120858
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 VIA DEL SOL, THE
FACILITY NUMBER: 306006485
VISIT DATE: 04/23/2025
NARRATIVE
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Based on the interviews conducted on April 17 & 18, 2025, two out of the two staff corroborated with the allegation indicating an oversight. A photograph of the check dated April 17, 2025 intended to be issued and mailed out to R1's representative was provided to LPA via text message during the visit at 3:49pm.

Based on the interviews and record review, it is determined that R1's representative was not reimbursed timely upon R1's death for January 10-31, 2025, therefore, the preponderance of evidence standard has been met and is deemed substantiated. See the attached LIC9099-D.

An exit interview was conducted with Chief Executive Officer Allen Medina and Director of Business/Attorney Keack Vongphakdy, and a copy of this report including the LIC811 and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3