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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006565
Report Date: 12/04/2025
Date Signed: 12/04/2025 09:33:42 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/01/2025 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20251201234600
FACILITY NAME:HILLS OF SIERRA MAJORCA, THEFACILITY NUMBER:
306006565
ADMINISTRATOR:LADIA, BHONALYNFACILITY TYPE:
740
ADDRESS:19105 SIERRA MAJORCATELEPHONE:
(949) 316-4654
CITY:IRVINESTATE: CAZIP CODE:
92603
CAPACITY:6CENSUS: 5DATE:
12/04/2025
UNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:Bhonalyn Ladia- Administrator TIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility staff did not refund resident's authorized person upon resident's death
INVESTIGATION FINDINGS:
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On this Day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit.

The Department received a complaint on 12/01/2025 and the initial 10 day visit was conducted on 12/04/2025. LPA Mendivil obtained copies of admission agreement for Resident 1 (R1) Regarding the allegation facility staff did not refund resident's authorized person upon resident's death, the investigation revealed the following:

It was reported that R1 had passed away on 09/03/2025, per admission agreement signed on 05/05/2025 on page 5 the refund policy is listed which states "the first 14 days upon moving into the community are non-refundable, anything after 14 days is refundable and will be based on a prorated amount"
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
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-20251201234600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HILLS OF SIERRA MAJORCA, THE
FACILITY NUMBER: 306006565
VISIT DATE: 12/04/2025
NARRATIVE
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Per interview with Owner/Licensee Allen Medina it was stated a refund was never issued to R1's family following their death and termination of admission agreement.

Therefore based on preponderance of evidence through interviews and records reviewed the allegation Facility staff did not refund resident's authorized person upon resident's death is determined to be SUBSTANTIATED, meaning the complaint allegation as valid and that a violation has occurred.

Based on above findings deficiencies are being cited per California Code of Regulations Title 22 Division 6 chapter 8.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20251201234600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HILLS OF SIERRA MAJORCA, THE
FACILITY NUMBER: 306006565
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/10/2025
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 stated will issue check via certified mail and provide proof to LPA by POC due date.
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This requirement was not met as R1's authorized representatives did not receive a refund. 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3