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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003618
Report Date: 06/23/2025
Date Signed: 06/23/2025 09:49:43 AM

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
01/05/2025 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250105223133
FACILITY NAME:NEIGHBORHOOD SUITES - COSTEAUFACILITY NUMBER:
306003618
ADMINISTRATOR:OFELIA ANGELESFACILITY TYPE:
740
ADDRESS:25005 COSTEAU STREETTELEPHONE:
(949) 290-6907
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 1DATE:
06/23/2025
UNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Ofelia AngelesTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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-Neglect/Lack of Care and Supervision resulting in a resident's death.
-Neglect/Lack of Care and Supervision resulted in resident's serious injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrived at facility and was greeted at the door by staff and granted entry. LPA spoke with Ofelia Angeles, Administrator and explained the purpose of the visit.

The complaint was investigated by the Department. Findings are based upon this investigation which included interviews with 6 staff and 5 witnesses and the following records review: medical records from Oasis Haven Hospice dated March 4, 2024, and County of Orange Death Certificate dated February 28, 2025, and resident’s facility file.

It is alleged Neglect/Lack of Care and Supervision resulting in a resident having a fall and sustaining a fractured hip and passed away. Resident (R1) moved into the facility on March 8, 2024, diagnosed with
Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
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 5
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
01/05/2025 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250105223133

FACILITY NAME:NEIGHBORHOOD SUITES - COSTEAUFACILITY NUMBER:
306003618
ADMINISTRATOR:OFELIA ANGELESFACILITY TYPE:
740
ADDRESS:25005 COSTEAU STREETTELEPHONE:
(949) 290-6907
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 1DATE:
06/23/2025
UNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Ofelia AngelesTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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-Neglect/Lack of Care and Supervision:The facility did not provide medical attention in a timely manner to a resident who suffered an unwitnessed fall resulting in a serious injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrived at facility and was greeted at the door by staff and granted entry. LPA spoke with Ofelia Angeles, Administrator and explained the purpose of the visit.

It is alleged Neglect/Lack of Care and Supervision: The facility did not provide medical attention in a timely manner to a resident who suffered an unwitnessed fall resulting in a serious injury. The complaint was investigated by the Department. Findings are based upon this investigation which included interviews with 6 staff and 5 witnesses and the following records review: medical records from Oasis Haven Hospice dated March 4, 2024, and County of Orange Death Certificate dated February 28, 2025, and resident’s facility file.

On December 2, 2024, resident (R1) sustained a fracture hip while in care due to an unwitnessed fall at
Continued on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
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 5
Control Number 22-AS-20250105223133
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: NEIGHBORHOOD SUITES - COSTEAU
FACILITY NUMBER: 306003618
VISIT DATE: 06/23/2025
NARRATIVE
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3:30 AM. Staff found R1 on the floor yelling for help due to the pain. Staff lifted R1 from the floor and placed back in bed. Staff did not notify the administrator or hospice until 8 AM. Hospice nurse assessed R1, and caring physician ordered mobile x-ray service. Mobile x-ray services were conducted on December 3, 2024, at 3:30 PM. Results reflecting a fractured left hip were received at 4:55 PM. Interview with staff revealed that they were instructed to notify hospice first when a resident is under the care of a hospice agency. Staff did not call 911 when R1 was found on the floor in great pain and discomfort. The staff lifted the resident off the floor in pain and placed the resident back in bed with no regard for the seriousness of their pain and possible injury.

During the course of the investigation, there was sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, this allegation is deemed Substantiated.

See LIC-9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations and the assessed immediate civil penalty in the amount of $500.
A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f).

An exit interview was conducted with the Administrator, and a copy of this report, Appeals Rights, and LIC-421IM Civil Penalty Assessment and the LIC-811, identifying confidential names were provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20250105223133
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: NEIGHBORHOOD SUITES - COSTEAU
FACILITY NUMBER: 306003618
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2025
Section Cited
CCR
87465(g)
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87465(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Licensee to provide staff in-services so all staff understand the regulation for Incidental Medical and Dental Care. Licensee to include date of inservice, topics covered and participant signature and email proof to LPA by POC due date.
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This requirement was not met as evidenced by:R1 sustained a fracture hip while in care due to an unwitnessed fall at 3:30am. R1 complained of pain. Staff did not notify administrator hospice till 8AM, which posed a potential health risk to persons in care. A civil penalty will be assessed.
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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: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20250105223133
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: NEIGHBORHOOD SUITES - COSTEAU
FACILITY NUMBER: 306003618
VISIT DATE: 06/23/2025
NARRATIVE
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Alzheimer’s and was receiving hospice care as need for R1’s on-going health conditions. R1 was able to ambulate around the facility with stand by assistance when mobile. The facility operates with three-four staff that reside in the home during their work-week shifts. The staff works 12-hour shifts and care for three-five residents. There is one caregiver for the overnight shift. The facility utilizes Oasis Haven Hospice as needed. On December 2, 2024, at about 3:30 AM, R1 requested assistance to go to the bathroom. Staff assisted R1 and staff went to help another resident with an activated motion sensor alarm. Upon return R1 was observed on the floor and appeared to be in pain and discomfort. Staff called Administrator and hospice company notifying them of the incident. Hospice nurse visited R1 at the facility and an x-ray was ordered by attending physician. X-ray results revealed that R1 had sustained a fracture left hip, due to R1’s age and health family was unable to find a surgeon for the reported injury. On December 6, 2024, R1 passed away at the facility under medical care of Oasis Haven Hospice. Interview with caring doctor for R1 stated that the cause of death was Alzheimer’s and not the reported injury. During the investigation there was not enough information to support the alleged allegations.

Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with the facility representatives and a copy of this LIC9099 report was left at facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5