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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300605337
Report Date: 01/27/2026
Date Signed: 01/27/2026 03:36:28 PM

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
10/06/2022 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20221006092156
FACILITY NAME:SUTTON FOUNDATION - REDROCKFACILITY NUMBER:
300605337
ADMINISTRATOR:DULCE FLORESFACILITY TYPE:
735
ADDRESS:21 REDROCK IRVINETELEPHONE:
(949) 551-2141
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:6CENSUS: 6DATE:
01/27/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jorge Gonzalez - Administrator TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff mismanaged resident medications
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit.

The Department received a complaint on 10/06/2022 and the initial 10 day visit was conducted on 10/11/2022. LPA Mendivil obtained copies of medication administrator records, Individual Program Plans, and behavior charts. LPA Mendivil also interviewed clients and staff. Regarding the allegations Staff mismanaged resident medications the investigation revealed the following:

It was reported that the staff mismanaged resident’s medication, per review of Client 1 (C1) was given medications after they were discontinued by their physician. Per review of the C1’s prescriptions dated 12/22/2021 Risperdal was discontinued effective 12/22/2021.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
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 22-AS-20221006092156
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: SUTTON FOUNDATION - REDROCK
FACILITY NUMBER: 300605337
VISIT DATE: 01/27/2026
NARRATIVE
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 Per Medication Administration Record from December 2021 the medication Risperdal was given after 12/22/2021 and was eventually discontinued on 12/26/2021. Per review of the MAR, no other medications errors were noted.

Therefore based on the preponderance of evidence through records reviewed the allegation staff mismanaged resident’s medication is determined to be SUBSTANTIATED, meaning the complaint allegation was valid and that a violation has occurred.



The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the Administrator.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20221006092156
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: SUTTON FOUNDATION - REDROCK
FACILITY NUMBER: 300605337
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2026
Section Cited
CCR
80075(b)
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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.This requirement was not met as evidence by facility did not follow physician's prescription in December 2021. This poses an immediate health and safety risk to persons in care.
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Administrator will provide LPA by with written plan regarding reviewing prescriptions and updating MAR by POC due date.
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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: 01/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/06/2022 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20221006092156

FACILITY NAME:SUTTON FOUNDATION - REDROCKFACILITY NUMBER:
300605337
ADMINISTRATOR:DULCE FLORESFACILITY TYPE:
735
ADDRESS:21 REDROCK IRVINETELEPHONE:
(949) 551-2141
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:6CENSUS: 6DATE:
01/27/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jorge Gonzalez - Adminstrator TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff forced resident to take medication against their will
Staff did not log resident medications as required
Resident is not provided required one to one care
Licensee is billing client for services not provided
Staff does not provide resident with activities
Staff denied resident access to the home for an extended period of time
Staff did not properly isolate sick residents in care
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit.

The Department received a complaint on 10/06/2022 and the initial 10 day visit was conducted on 10/11/2022. LPA Mendivil obtained copies of medication administrator records, Individual Program Plans, and behavior charts. LPA Mendivil also interviewed clients and staff. Regarding the allegations Staff forced resident to take medication against her,Staff did not log resident medications as required, Resident is not provided required one to one care, Licensee is billing client for services not provided, Staff does not provide resident with activities ,Staff denied resident access to the home for an extended period of time, Staff did not properly isolate sick residents in care, the investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20221006092156
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: SUTTON FOUNDATION - REDROCK
FACILITY NUMBER: 300605337
VISIT DATE: 01/27/2026
NARRATIVE
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It was reported that staff was forcing residents to take medication against their will. Per interviews with 5 out of 5 staff stated they do not force residents to take medications against their will. Per interviews with 1 out of 6 clients staff does not force them to take their medications. 5 clients were not available due to 2 clients are out of the facility in Day program and the remaining 3 were not oriented to time and space.
Per review of medication administration record (MAR) for Client 1 (C1) all medications were logged for the period of December 2021 to August 2022. Per staff medication administration and refusals are also logged on MAR.
Per interviews with 5 out of 5 staff stated C1 is receiving 1:1 care. Per interviews there were 3 staff members that were rotating 1:1 care in 2022. Currently there 3 staff members providing 1:1 for the allotted 12 hours which was determined by Regional Center of Orange County, therefore Licensee is providing services that are billed.
It was alleged the facility does not provide activities, per review of pictures sent to LPA from 2022 clients went to Disneyland and other activities. Staff stated not all clients want to participate in all activities such as walking or playing outside. Interviews with 5 out of 5 staff stated they cannot force a client to participate in activities.
It was alleged that staff denied resident access to the home for an extended period of time. Per interviews 5 out of 5 staff stated clients have not been denied access to the home. Review of incident reports from July 2022 it was reported that C1 was sent out to the hospital due to covid symptoms and returned back to facility when discharged.
It was reported that Staff did not properly isolate sick residents in care. Per interviews with 3 out of 5 staff stated they followed the current Provider Information Notices (PINs) in 2022 for isolation. Staff reported that clients could stop isolation after at least 10 days after symptoms appear. The remaining 2 staff members were not in management and were not aware of PINs.
Therefore based on the preponderance of evidence through records reviewed and interviews the allegations Staff forced resident to take medication against her,Staff did not log resident medications as required, resident is not provided required one to one care, Licensee is billing client for services not provided, Staff does not provide resident with activities ,Staff denied resident access to the home for an extended period of time, Staff did not properly isolate sick residents in care are determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of this report and LIC 811 provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5