306006592-9-30-2025-22-AS-APAO-DM93XN-20251007183837

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006592
Report Date: 09/30/2025
Date Signed: 09/30/2025 12:57:04 PM

Unsubstantiated

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
09/10/2025 and conducted by Evaluator Claudia Gutierrez

COMPLAINT CONTROL NUMBER: 22-AS-20250910164026

FACILITY NAME:	CHESTNUT COVE		FACILITY NUMBER:	306006592
ADMINISTRATOR:	BUGASTO, MYRNA		FACILITY TYPE:	740
ADDRESS:	1225 E CHESTNUT ST.		TELEPHONE:	(714) 306-3523
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY:	6	CENSUS: 5	DATE:	09/30/2025
		UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Dave Sombilon		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility staff left resident lying on the floor
Facility staff did not assist resident with hygiene as needed
Facility staff did not assist resident with incontinence care as needed

INVESTIGATION FINDINGS:

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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Staff Dave Sombilon and explained the purpose of the inspection.

Regarding the allegation Facility staff left resident lying on the floor, the following was revealed: It is alleged Facility staff left Resident 1 (R1) lying on the floor. During the course of the investigation, interviews were conducted with R1, two additional facility residents, three witnesses, and two staff.

Per R1’s Physician Report dated September 19, 2025, R1 can be confused and forgetful due to their medical diagnosis. During their interview, R1 did not disclose any staff neglect but was unable to confirm or deny the allegation.During their interview, Resident 2 (R2) denied having any knowledge of staff leaving any resident lying on the floor and stated R1 has a history of yelling at facility staff and throwing themselves on the floor. (Cont. LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
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)

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Control Number 22-AS-20250910164026

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: 09/30/2025

NARRATIVE

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During their interview, Resident 3 (R3) denied having any knowledge of staff leaving any resident lying on the floor and stated they were not familiar with, nor did they know R1. Per R3, staff is always available to assist them, and they can use their call button to call for help and staff will almost always come to their aid immediately.

During their interview, Staff 1 (S1) denied personally leaving any resident lying on the floor and denied having any knowledge of any other facility staff leaving any resident, including R1 to lying on the floor. Per S1, on August 30, 2025, R1 was upset they had not received a visit from Witness 2 (W2), which lead to R1 throwing themselves on the floor. Per S1, they felt R1 was a threat to themselves and others due to pulling out their own hair and kicking S2. S1 stated they called 911 and R1 was placed on a psychiatric hold. During their interview, Staff 2 (S2) denied personally leaving any resident lying on the floor and denied having any knowledge of any other facility staff leaving any resident, including R1 lying on the floor. Per S2, on August 30, 2025, staff made the decision to call 911 after R1 slipped from their bed onto the floor and refused to allow staff to assist them getting up. S2 stated they attempted to assist R1 but R1 kicked them, and it was then they and S1 no longer felt safe and called 911.

During their interview, Witness 1 (W1) denied R1 informing them, or having any knowledge of staff leaving R1 lying on the floor. W1 stated they did not have any concerns regarding the facility staff and denied R1 sharing any concerns regarding the facility or staff. During their interview, Witness 2 (W2) denied having any knowledge of staff leaving R1 lying on the floor. W2 stated they did not have any concerns regarding the facility staff and denied R1 sharing any concerns regarding the facility or staff. During their interview, Witness 3 (W3) stated they did not know any specifics but stated R1 had been complaining about the care at the facility, however, was unable to provide further information.

Regarding the allegation Facility staff did not assist resident with hygiene as needed, the following was revealed: It is alleged staff did not assist R1 with hygiene as needed. During their interview, R1 denied the allegation and stated staff assist them with all grooming and hygiene needs. Per R1, at the time of their interview, staff had just assisted them with a bed bath. LPA observed R1 with combed wet hair and a clean appearance. During their interview, Resident 2 (R2) denied having any knowledge of any resident being unkempt and stated facility staff have been and continue to be helpful. Per R2, they initially felt uncomfortable with male caregivers assisting them in the shower, but the staff make them feel safe and they now enjoy and actually look forward to their showers. (Cont. LIC9099-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
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)

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Control Number 22-AS-20250910164026

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: 09/30/2025

NARRATIVE

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During their interview, Resident 3 (R3) denied having any knowledge of any resident being unkempt and stated staff is always available to assist them. During their interview, S1 denied facility staff not assisting R1 or any other resident with hygiene. Per S1, on August 30, 2025, after R1 threw themselves on the floor, R1 removed their bottoms and defecated on their bedroom floor. S1 stated they attempted to clean R1 prior to paramedics arriving but R1 was resistant. Per S1, R1's hair became disheveled due to R1 running their fingers through their hair and pulling it out. During their interview, S2 denied facility staff not assisting R1 or any other resident with hygiene. Per S2, staff always assist R1 with grooming and bathing and stated that upon R1’s admission to the facility, R1’s hair had been matted, and a brush could not be run through their hair. S2 stated staff have been washing R1’s hair regularly and R1’s hair is now soft enough to brush. Per S2, on August 30, 2025, after R1 threw themselves on the floor, R1 removed their bottoms and defecated on their bedroom floor. S2 stated they attempted to clean R1 but R1 was resistant and kicked them.

During their interview, Witness 1 (W1) denied witnessing or having any knowledge of R1’s appearance being unkempt and stated they did not have any concerns regarding the facility staff and denied R1 sharing any concerns regarding the facility or staff. During their interview, Witness 2 (W2) denied witnessing or having any knowledge of R1’s appearance being unkempt and stated they did not have any concerns regarding the facility staff and denied R1 sharing any concerns regarding the facility or staff. During their interview, Witness 3 (W3) stated they did not know any specifics but stated R1 had been complaining about the care at the facility, however, was unable to provide further information.

Regarding the allegation Facility staff did not assist resident with incontinence care as needed, the following was revealed: It is alleged staff did not assist R1 with incontinence care as needed. During their interview, R1 denied the allegation and stated staff always assist them with incontinence care. During their interview, Resident 2 (R2) denied having any knowledge of R1 or any other resident sharing any concerns regarding staff or staff being unwilling to help them with incontinence care. R2 denied witnessing R1’s or any other residents' appearance to be unkempt. R2 stated facility staff have been and continue to be helpful. During their interview, Resident 3 (R3) denied having any knowledge of any resident sharing any concerns regarding staff or staff being unwilling to help them with incontinence care and denied witnessing any other residents' appearance to be unkempt. During their interview, S1 denied facility staff not assisting R1 or any other resident with incontinence care. Per S1, on August 30, 2025, after R1 threw themselves on the floor, R1 removed their bottoms and defecated on their bedroom floor. S1 stated they attempted to clean R1 prior to paramedics arriving but R1 was resistant. (Cont. LIC9099-C)

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
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: 3 of 4

Control Number 22-AS-20250910164026

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: 09/30/2025

NARRATIVE

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During their interview, S2 denied facility staff not assisting R1 or any other resident with incontinence care. Per S2, on August 30, 2025, after R1 threw themselves on the floor, R1 removed their bottoms and defecated on their bedroom floor. S2 stated they attempted to clean R1 but R1 was resistant and kicked them.

During their interview, Witness 1 (W1) denied witnessing or having any knowledge of staff not assisting R1 with incontinence care. Per W1, they have no concerns regarding the facility and R1 has never shared any concerns with them. W1 stated that as far as they are aware R1 is well taken care of. During their interview, Witness 2 (W2) denied witnessing or having any knowledge of staff not assisting R1 with incontinence care. Per W2, R1 had been asked if they were okay with returning to the facility following their hospitalization and R1 had no objections. During their interview, Witness 3 (W3) stated they did not know any specifics but stated R1 had been complaining about the care at the facility, however, was unable to provide further information.

Due to allegations being uncorroborated during interviews conducted, the Department is unable to determine if Facility staff left resident lying on the floor, iff Facility staff did not assist resident with hygiene as needed, or if Facility staff did not assist resident with incontinence care as needed. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore at this time the above allegations are unsubstantiated.

An exit interview was conducted and copy of this report was provided at the end of the inspection.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
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)

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