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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300612904
Report Date: 05/01/2025
Date Signed: 05/01/2025 02:04:06 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
04/21/2025 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20250421115146
FACILITY NAME:ADELINE GUEST HOMEFACILITY NUMBER:
300612904
ADMINISTRATOR:ADELINA MONCERAFACILITY TYPE:
740
ADDRESS:741 N. EAST STREETTELEPHONE:
(714) 996-0568
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:6CENSUS: 4DATE:
05/01/2025
UNANNOUNCEDTIME BEGAN:
07:53 AM
MET WITH:Ruby Cruz- House Manager TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff does not ensure facility is free of pests.
Staff does not ensure facility is free of mildew.
Staff does not ensure facility faucet is in good repair.
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. House Manager Ruby Cruz arrived shortly after.

The Department received a complaint on 04/21/2025 and the initial 10 day visit was conducted on 05/01/2025. LPA Mendivil interviewed staff and residents and obtained copies of pertinent documents such as invoices for exterminator. Regarding the allegations that Staff does not ensure facility is free of pests, Staff does not ensure facility is free of mildew, and Staff does not ensure facility faucet is in good repair, the investigation revealed the following:

Based on observation LPA Mendivil noticed small dead roaches behind a dresser in a residents bedroom and live roaches in kitchen pantry. Per interviews with staff and residents an exterminator came out yesterday 04/30/2025 and sprayed around the house.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
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 4
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
04/21/2025 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20250421115146

FACILITY NAME:ADELINE GUEST HOMEFACILITY NUMBER:
300612904
ADMINISTRATOR:ADELINA MONCERAFACILITY TYPE:
740
ADDRESS:741 N. EAST STREETTELEPHONE:
(714) 996-0568
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY:6CENSUS: 4DATE:
05/01/2025
UNANNOUNCEDTIME BEGAN:
07:53 AM
MET WITH:TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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2
3
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9
Staff speaks inappropriately about resident in the presence of facility visitors,
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. Administrator Adelina Moncera arrived shortly after.
The Department received a complaint on 04/21/2025 and the initial 10 day visit was conducted on 05/01/2025. LPA Mendivil interviewed staff and residents and obtained copies of pertinent documents such as staff trainings and staff schedule. Regarding the allegation that staff speaks inappropriately about resident in the presence of facility visitors, the investigation revealed the following:
Based on interviews with 3 out of 4 residents stated they have not heard staff speak inappropriately about another resident in a visitors presence. The remainig resident did not provide answers as 1 did not want to be interviewed. 3 out of 3 staff deny the allegation. Therefore the allegation is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
An exit interview was conducted and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20250421115146
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: ADELINE GUEST HOME
FACILITY NUMBER: 300612904
VISIT DATE: 05/01/2025
NARRATIVE
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LPA Mendivil observed mildew in the main bathroom in the hallway, 3 out of 3 staff stated the shower is cleaned daily.

LPA Mendivil observed a faucet in bathroom in shared bedroom to be loose and not properly attached to counter top.

Therefore based on observations and interviews the allegations that Staff does not ensure facility is free of pests, Staff does not ensure facility is free of mildew and staff does not ensure facility faucet is in good repair are determined to be SUBSTANTIATED meaning the complaint allegation is 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 facility representative.

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

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20250421115146
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: ADELINE GUEST HOME
FACILITY NUMBER: 300612904
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2025
Section Cited
CCR
87303(a)(1)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times...(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
This requirement was not met as evidence by LPA observed mildew in hallway bathroom.
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House Manager agreed to have repairs done to facility shower and replace faucet and provide proof of POC to LPA by due date.
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and broken faucet in bathroom in shared bedroom. This poses a potential health and safety risk to persons in care,
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Type B
05/07/2025
Section Cited
CCR
87307(d)(2)
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(d) The following space and safety provisions shall apply to all facilities:
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidence by LPA observed
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Corrected during visit. Staff cleaned out pantry and removed all dead roaches from room. Facility hired an exterminator which came out to facility on 04/30/2025 and will visit monthly per contract provided.
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roaches in both living and dead in different locations in the facility. This poses a potential health and safety risks 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: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4