306000638-1-29-2026-22-AS-AORZ-DR6T32-20260210132135

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000638
Report Date: 01/29/2026
Date Signed: 01/29/2026 11:46:38 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
08/05/2025 and conducted by Evaluator RoseMarie Ruppert

COMPLAINT CONTROL NUMBER: 22-AS-20250805140648

FACILITY NAME:	3K HOME CARE		FACILITY NUMBER:	306000638
ADMINISTRATOR:	MARIA N.G. MANIMBO		FACILITY TYPE:	740
ADDRESS:	700 S. PLYMOUTH PLACE		TELEPHONE:	(714) 774-8653
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY:	6	CENSUS: 0	DATE:	01/29/2026
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Maria Nelly G. Manimbo, Licensee/Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility did not provide written notice prior to rent increase.
Facility falsely claimed resident needed a higher level of care.

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Rose Ruppert met with Licensee Maria Manimbo and explained the purpose of the visit was to deliver findings for the above allegations. It was alleged the facility did not provide written notice prior to rent increase and the facility falsely claimed resident needed a higher level of care. The investigation determined as follows:

Regarding the allegation that the facility did not provide written notice prior to rent increases, the Department reviewed Resident #1 (R1)’s Admission Agreement, dated November 3, 2023, when R1, a 62-year-old male, was admitted to the facility. R1 paid the rate for a shared bedroom for $3500 per month per Admission Agreement. Three weeks later, on November 24, 2023, an email was sent to R1 with the subject line stating: 30 days’ Notice of Increase or to move out. Per email the rate would increase to $5500 per month due to a higher level of care . No documentation was provided regarding the reassessment.

(Continued on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

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 4

Control Number 22-AS-20250805140648

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: 3K HOME CARE	FACILITY NUMBER: 306000638
	VISIT DATE: 01/29/2026

NARRATIVE

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(Continued from LIC 9099)

Upon review of R1’s file, R1’s admission agreement was altered via handwritten note to show an effective date of December 3, 2023, with a new rate of $5500. On this same page, another handwritten note states on May 7, 2024, the resident transferred to a private room. R1’s admission agreement was again altered via handwritten note to show an effective date of August 3, 2024, with a new rate of $6500. R1 did not receive a written notice by the licensee documenting these changes. There are no signed documents with R1’s signature stating proof of notice was received. Thus, the allegation that the facility did not provide written notice prior to rent increase is Substantiated.

Regarding the allegation the facility falsely claimed resident needed a higher level of care, R1’s initial Physician’s Report LIC 602A, dated November 3, 2023, stated R1’s primary diagnosis was Multiple Sclerosis. The report stated R1 had bowel and bladder impairment, motor impairment/paralysis, required continued bed care and has a history of skin condition or breakdown and is bedridden. The facility license, effective October 2, 1997, has a fire clearance for four non-ambulatory with a hospice waiver for two. R1 was initially admitted under the care of hospice services. Per interview with hospice agency, R1 was declining at a rapid rate and was not expected to live as long as R1 has. The Appraisal Needs and Services Plan, dated November 30, 2023, documents the need for a higher level of care in handwritten notes. These notes were handwritten over the initial Appraisal Needs and Services Plan and notates November 15 and November 21, 2023, assessments. It is unclear when the initial Needs and Services Plan was dated and signed due to page four of the document missing. An updated Physician’s Report was not found in R1’s records, indicating no change in R1’s medical condition from the initial needs identified and agreed to by the Licensee at the time R1 was admitted. An email on Friday, November 24, 2023, was provided to R1 stating a rate increase of $2000 due to higher level of care, with no clarification or documentation of the higher level of care required. Thus, the allegation that the facility falsely claimed resident needed a higher level of care is Substantiated.

(Continued on LIC 9099-C1)

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20250805140648

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: 3K HOME CARE	FACILITY NUMBER: 306000638
	VISIT DATE: 01/29/2026

NARRATIVE

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(Continued from LIC 9099-C)

Based on records reviewed and interviews conducted the preponderance of evidence standard has been met. Therefore, the allegations that the licensee did not provide written notice prior to rent increase and facility falsely claimed resident needed a higher level of care are Substantiated.

The following deficiencies are being cited per California Code of Regulations, Title 22 Division 6.
An exit interview was conducted with Maria Manimbo and a copy of this report, Confidential Names List, LIC9099-D, and appeal rights were provided.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20250805140648

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: 3K HOME CARE	FACILITY NUMBER: 306000638
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/30/2026 Section Cited CCR 87207	1 2 3 4 5 6 7	False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on Dept. record review, observations	1 2 3 4 5 6 7	Licensee (LE) will submit documentation of R1's change of condition. LE will submit the Appraisal Needs and Services plan prior to R1's admission from November 22 and November 30th and Physician's Reports (LIC 602A) from the Skilled Nursing Facility and Hospice Medical Assessment.
	8 9 10 11 12 13 14	& interviews the Licensee claimed R1 required a higher level of care resulting in an increase of fees from $3500 to $6500. No increase in level of care was documented as required. This poses an immediate risk for residents in care.	8 9 10 11 12 13 14	LE will ensure all documentation related to investigations are provided to the Department. LE will submit by POC due date.
Type A 01/30/2026 Section Cited HSC 1569.657(a)	1 2 3 4 5 6 7	For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident …written notice of the rate increase … The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization	1 2 3 4 5 6 7	LE will provide resident notice with descrption and itemizations for level of care needs which require a rate increase. LE will provide LPA with Policy and Procedures regarding rate increases by POC due date.
	8 9 10 11 12 13 14	of the charges. This requirement is not met as evidenced by: Based on Dept. record review, observations & interviews the licensee did not provide a written notice of a rate increase detailing additional services to be provided at new level of care	8 9 10 11 12 13 14	(Cont.'d) or accompanying itemization of charges prior to implementing rent increase for R1. As a result, R1 lacked funds for future rent. This poses an immediate, safety and personal rights risk for persons in care.

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: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC9099 (FAS) - (06/04)

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