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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197803389
Report Date: 05/07/2026
Date Signed: 05/07/2026 05:16:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2026 and conducted by Evaluator Socorro Leandro
COMPLAINT CONTROL NUMBER: 11-AS-20260501095056
FACILITY NAME:ORANGE COMMUNITY CAREFACILITY NUMBER:
197803389
ADMINISTRATOR:SAAFIR, AHMEDFACILITY TYPE:
735
ADDRESS:2103 ORANGE AVENUETELEPHONE:
(562) 599-0856
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY:36CENSUS: 25DATE:
05/07/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee - SAAFIR, AHMEDTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not ensure client took medication as prescribed.
INVESTIGATION FINDINGS:
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On 05/07/2026, Licensing Program Analyst (LPA) Socorro Leandro initiated a complaint investigation regarding the allegation listed above. LPA met with the Administrator, Ahmed Saafir, and the purpose of the visit was explained. The LPA was allowed entry to the facility.

The investigation consisted of the following:

Interviews were conducted with Staff 1 (S1) to Staff 3 (S3), Cient 1 (C1), and Witness 1 (W1) and Medications alongside Medication Administration Records (MARs) were reviewed. Records gathered consisted of Plan of Operation, Resident Roster, Staff Roster, C1’s records, and other pertinent records were gathered.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026
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 5
Control Number 11-AS-20260501095056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ORANGE COMMUNITY CARE
FACILITY NUMBER: 197803389
VISIT DATE: 05/07/2026
NARRATIVE
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The investigation revealed the following:

Allegation: “Staff did not ensure client took medication as prescribed”, it is being alleged that C1 did not take medication as prescribed.

Records reviewed of Plan Of Operation revealed the following:

“Self-administered Medication
WHAT YOU AT THIS FACILITY SHOULD DO WHEN:
1. Client/resident arrives with medications:
· Contact physician(s) to ensure physician is aware of all medications currently taken by the client/resident.
· Verify medications that are currently taken by the client/resident and instructions for disbursement.
· Inspect containers to ensure the labeling is accurate.
· Log medications accurately on forms for client/resident records.
· Discuss medications with the client/resident, if possible or the responsible person/authorized representative.
· Store medications in a locked cabinet, drawer, etc.
2. Medication is refilled:…
· Inspect containers to ensure all information on the label is correct.
· Note any changes in instructions and/or medication; for example, change in dosage, change to generic brand, etc.
· Log medication when received.
· Discuss any changes in medications with client/resident, responsible person/authorized representative and appropriate staff…
5. Client/resident refuses medications:…
· Refusal of medications should be documented on the client's/residents medication record and the prescribing physician contacted Immediately.”
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20260501095056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ORANGE COMMUNITY CARE
FACILITY NUMBER: 197803389
VISIT DATE: 05/07/2026
NARRATIVE
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C1’s records reviewed revealed the following:

· Admission Agreement indicates that C1 was admitted to the facility on 03/03/2026.

· House Rules states “4. Medication can only be given as prescribed.” signed by C1 on 03/03/2026.

· C1’s March 2026 MAR was blank, document was not filled in by staff.

C1’s Medications reviewed along with MARs from April to May 2026 revealed the following:

· Busprirone Tab 15 MG MAR do not have staff initials on 5:00 PM for 04/20/2026, 04/30/2026, 05/02/2026, 05/03/2026, 05/06/2026; the medication for those exact dates are not in bubble pack; there is no documentation as to why staff did not initial.
· Diclofenac Gel 1% MAR do not have staff initials on 5:00 PM for 04/16/2026, 04/20/2026, 04/25/2026 to 04/27/2026, 04/29/2026 to 05/06/2026 and for 9:00 PM on 04/20/2026, 04/20/2026, 04/25/2026 to 04/27/2026, 05/03/2026, and 05/06/2026; there is no documentation as to why staff did not initial.
· Gabapentin Cap 100 MG are documented twice on the MAR the first documentation is from 8:00 AM, 12:00 PM, and 5:00 PM the second is documented from 8:00 AM, 5:00 PM, and 9:00 PM; both have staff initials for each time frame and both are missing staff initials; there is no explanation as to why staff did not initial. The medication bubble pack for noon has medication still in the present for 04/09/2026, 04/13/2026, 04/14/2026, 04/15/2026, 04/17/2026 to 04/22/2026, 04/24/2026, 04/28/2026 to 04/30/2026, 05/04/2026 to 05/06/2026.
· Lidocaine Cream 3% do not have staff initials on 8:00 AM 05/01/2026, 12:00 PM 05/02/2026 to 05/03/2026, and 5:00 PM 04/20/2026, 04/25/2026 to 04/27/2026, 04/30/2026 to 05/04/2026, and 05/06/2026; there is no explanation as to why staff did not initial.
· Meloxicam Tab 7.5 MG do not have staff initials on 8:00 AM on 05/02/2026 to 05/03/2026, and 5:00 PM from 04/09/2026 to 05/06/2026; there is no explanation as to why staff did not initial. The morning bubble pack still had the medication for 04/09/2026 and the evening bubble pack still had the medication for 04/27/2026.
There are seven other medications with discrepancies; ranging from medications not provided with no explanation as to why they were not provided to medications on MAR seen to be provided but when medication was checked they were present in the medication container.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20260501095056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ORANGE COMMUNITY CARE
FACILITY NUMBER: 197803389
VISIT DATE: 05/07/2026
NARRATIVE
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Interviews conducted with S1 to S3, C1, and W1 reveled the following:

S3 indicated that C1 provided them with medications on two separate occasions but they did not document medications. S1 and S2 indicated that they did not document medications that were provided to S3.

C1 indicated that they provided medications to S3. C1 indicated that they received said medications, but the facility did not follow the doctor’s orders.

W1 a physician agrees with the allegation; furthermore, W1 indicated that they reached out to the facility due to medication errors. W1 indicated that the facility did not reach out to them previously.

Substantiated: Based on observations, interviews and record reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20260501095056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ORANGE COMMUNITY CARE
FACILITY NUMBER: 197803389
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2026
Section Cited
CCR
80022(k)
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80022 Plan of Operation (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.

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The licensee has agreed to re-read their plan of operation and follow it and retrain their staff on Medication Administration, provide clients with medications as prescribed.

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Based on observation, interviews, and records reviewed the licensee did not follow their plan of operations regarding medication administration which poses/posed a potential health, safety or personal rights risk to persons in care.
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Email proof of correction to
Socorro.Leandro@dss.ca.gov
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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: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5