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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006495
Report Date: 09/30/2025
Date Signed: 09/30/2025 05:03:56 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
06/25/2025 and conducted by Evaluator Edward Kim
COMPLAINT CONTROL NUMBER: 22-AS-20250625152918
FACILITY NAME:HILLS OF SANTA TERESA, THEFACILITY NUMBER:
306006495
ADMINISTRATOR:NEPOMUCENO, MARICELFACILITY TYPE:
740
ADDRESS:17698 SANTA TERESA CIRCLETELEPHONE:
(714) 430-7672
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
09/30/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Director of Operations- Johanna GomezTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Facility is in financial distress.
INVESTIGATION FINDINGS:
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On September 30, 2025, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Director of Operations (DOP) Joanna Gomez and explained the purpose of today’s visit.

The investigation consisted of the following: LPA Kim conducted an initial visit on June 30, 2025, and subsequent visit on July 21, 2025. LPA Kim obtained and reviewed copies of the resident and staff rosters, resident records which include the Physician’s Reports, Appraisal/Needs and Services Plans, and other pertinent records for five staff.

Allegation: Facility is in financial distress
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
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 3
Control Number 22-AS-20250625152918
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 SANTA TERESA, THE
FACILITY NUMBER: 306006495
VISIT DATE: 09/30/2025
NARRATIVE
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It is alleged that staff were not paid in a timely manner and had no response from the Licensee. LPA conducted six staff Interviews who all confirmed the allegation. However, five out of six staff refused to provide evidence of their claims. All staff stated that the payment schedule is on 7th and the 22nd day of the month. All staff stated they submit their timesheets on the 3rd and the 18th of the month. All staff reported experiencing at least one instance where their paycheck was delayed by one day to a week beyond the scheduled pay date.

Based on record reviews, LPA observed one staff member received three letters from their bank of non-sufficient payments from the Licensee. The checks deposited on April 30, 2025, in the amount of $176.46, June 11, 2025, in the amount of $1333.52, and June 27, 2025, in the amount of $1178.09 have been returned unpaid due to non-sufficient funds. Licensee replaced the bounced checks at a later date without responding to staff’s inquiries about insufficient funds.

Therefore, based on LPA's observations, interviews, and records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility is in financial distress is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. A deficiency is being cited on the attached LIC9099D.

Exit interview was conducted, and a copy of the report, LIC9099D,and the appeal rights were provided to Director of Operations Joanna Gomez.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250625152918
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 SANTA TERESA, THE
FACILITY NUMBER: 306006495
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2025
Section Cited
CCR
87213
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87213 The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents...
This requirement is not met as evidenced by:
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Licensee states they will pay staff in a timely manner and ensure checks do not get returned. They will send a Statement of Understanding of the CCR 87213 and state they understand, read, and provide a signature and send proof via email to edward.kim@dss.ca.gov by 10/14/2025
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Based on observations, record review, and interviews, the paychecks issued to staff were returned due to insufficient funds. This poses a potential 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: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3