306002568-1-5-2026-22-AS-APAO-DQ5QTR-20260108112732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002568
Report Date: 01/05/2026
Date Signed: 01/05/2026 12:58:54 PM

Unsubstantiated

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
01/14/2021 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210114172609

FACILITY NAME:	SUNRISE AT YORBA LINDA		FACILITY NUMBER:	306002568
ADMINISTRATOR:	MARIA DOMINGO		FACILITY TYPE:	740
ADDRESS:	4792 LAKEVIEW AVE		TELEPHONE:	(714) 693-5368
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	93	CENSUS:	DATE:	01/05/2026
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Tyler Hawk, executive director		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Resident was neglected and lack of supervision.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegation listed above as well as to deliver findings to the facility. LPA was greeted and granted entry by facility staff after introducing himself, stating the purpose of the visit and stating the allegation under review.

The initial complaint investigation visit was conducted remotely on January 20, 2021 due to COVID-19-related restrictrictions in place at the time. During the remote visit, licensing staff spoke to Maria Domingo, Executive Director and requested copies of pertinent documents regarding resident R1 to be delivered via email. Additional email follow-up was conducted with facility staff during the investigation.

CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026

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-20210114172609

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: SUNRISE AT YORBA LINDA	FACILITY NUMBER: 306002568
	VISIT DATE: 01/05/2026

NARRATIVE

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CONTINUED FROM FORM LIC9099
Regarding the allegation that Resident fell due to lack of care and supervision, the following has been concluded: Based on the resident records provided by facility staff and reviewed during the investigation, R1 was admitted to the facility on May 28, 2019. At the time of admission, R1 was assessed to be ambulatory, with a primary diagnosis of Atrial fibrillation, hypertension, chronic kidney disease III, macular degeneration. R1 was assessed to be able to manage their own medication at the time and no indication of Mild cognitive impairment or dementia were noted at the time. Regular updates to R1's plan of care are noted based on changes in condition. For example, as of February 2020, R1 was placed on medication management. Per the physician orders reviewed, R1 had a PRN order for Albuterol which was documented to be administered regularly due to recurring shortness of breath. On or around January 12, 2021, R1 sustained an unwitnessed fall resulting in lacerations to the head which resulted in a call to the paramedics and evaluation at the hospital. R1 tested positive for COVID-19 while at the hospital and was placed on isolation as required upon being readmitted to the facility.
As a result of the fall and COVID-19 diagnosis, recurrent follow-up assessments were conducted in the weeks that followed. Per incident reports submitted as well as charting notes reviewed, no other fall incidents occurred during R1's admission at the facility. R1 eventually passed while under hospice care in January 2024.

The documentation reviewed fails to sufficiently evidence that inadequate supervision was being provided to R1 which would have resulted in the fall reported in January 2021. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026

LIC9099 (FAS) - (06/04)

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