<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006592
Report Date: 06/04/2025
Date Signed: 06/04/2025 03:18:56 PM

Unfounded


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
05/28/2025 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250528163140
FACILITY NAME:CHESTNUT COVEFACILITY NUMBER:
306006592
ADMINISTRATOR:BUGASTO, MYRNAFACILITY TYPE:
740
ADDRESS:1225 E CHESTNUT ST.TELEPHONE:
(714) 306-3523
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:6CENSUS: 4DATE:
06/04/2025
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Dave SombilonTIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide 60-day notice prior to rent increase.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Complaint Investigation regarding the allegation mentioned above. LPA met with Staff Dave Sombilon. Licensee Representative (LR) Janice Jabonero was contacted by phone at arrived at approximately 1:45 p.m.

During the course of the investigation, LPA conducted a record review for four of four resident files. One of four resident admission agreements was observed to have basic service fee of $4,000 a month and the following handwritten statement was on the first page: “Rent for basic services will increase to $4,500 a month as of 9/01/202[5]." At the bottom of the first page of the agreement the following handwritten statement was observed: “June 2024 rent will be $3000 due to overcharge collect by Chestnut Cove worth $1,000."

Interviews were conducted with LR, Resident 1 (R1), and R1’s responsible party, Witness 1 (W1). During their interview, R1 stated they default to W1 on most personal and financial matters. (Cont. LIC9099-C)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
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 2
Control Number 22-AS-20250528163140
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: CHESTNUT COVE
FACILITY NUMBER: 306006592
VISIT DATE: 06/04/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
For this reason, R1 stated they did not negotiate the terms and conditions of the admission agreement and left it to W1 to “sort out.” During their interview, W1 stated it had all been “an innocent mistake” and provided a written statement which read in part: “The issue was due to an error in the paperwork for my husband’s assisted living fees. I hope that my ability to clear up this misunderstanding allows the Department of Social Services to also clear up the issue.” During their interview, LR stated that the original agreed upon basic service fee was $4,500, however, the amount had originally been left blank at the time that the admission agreement was signed. LR stated that once W1 informed them they were being overcharged, a meeting was held with all parties involved and the handwritten statements were added to the first page of the admission agreement, in order to honor W1’s believe that basic service fee was that of $4,000 and allow the proper 60-day notification for rent increase to take place.

The Department has investigated the complaint alleging Staff did not provide 60-day notice prior to rent increase. Based upon resident file review, written statements provided, and interviews conducted, We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2