306003820-7-16-2026-22-AS-APAO-DWXP8J-20260814110538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003820
Report Date: 07/16/2026
Date Signed: 07/16/2026 03:42:09 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
03/03/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230303155354

FACILITY NAME:	ADRIANA ELDERLY CARE HOME I		FACILITY NUMBER:	306003820
ADMINISTRATOR:	MENDOZA, RICHARD		FACILITY TYPE:	740
ADDRESS:	25342 ADRIANA STREET		TELEPHONE:	(949) 859-9894
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	07/16/2026
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Richard Mendoza		TIME COMPLETED:	02:44 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not turn resident every hour.
Staff refused resident medical attention.
Staff confiscated resident's personal items.
Staff did not allow resident phone calls.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to complete the investigation and deliver findings on the allegations listed above. LPA was greeted and granted entry by staff after explaining the reason for the visit.

The complaint investigation consisted of interviews and document review.

Regarding the allegation: Staff did not turn resident every hour
10 of 10 individuals failed to provide any corroborating information or evidence to support the complaint allegation. Just about everyone interviewed said Resident 1 (R1) is rotated or repositioned every two hours. According to one individual, R1 is rotated between 6-8 times a day. According to the Executive Director (ED) Richard Mendoza, R1 is not bed-bound, but the resident needs assistance repositioning every two hours. According to ED Mendoza, assistance with repositioning is documented on R1 care plan.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

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 2

Control Number 22-AS-20230303155354

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: ADRIANA ELDERLY CARE HOME I	FACILITY NUMBER: 306003820
	VISIT DATE: 07/16/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation: Staff refused medical attention.
10 of 10 individuals failed to provide any corroborating information or evidence to support the complaint allegation. According to ED Mendoza, R1 was sent to the hospital at the recommendation of a physician after a routine doctor's appointment. ED Mendoza explained an incident when R1 was taken to the hospital after a friend of R1 called 911. When the paramedics arrived to transport the resident, no one knew what was going on because the friend called 911 from outside the facility and did not notify facility staff about the reason for the call. R1 was eventually sent to the hospital after paramedics assessed the resident. Document review revealed R1 did receive medical care and attention as there were several Kaiser discharge summary’s for medical treatment R1 received.

Regarding the allegation: Staff confiscated residents personal items.
10 of 10 individuals failed to provide any corroborating information or evidence to support the complaint allegation. It is unclear what exactly was confiscated from R1, but the resident denied the complaint allegation. R1 denied anyone confiscated their personal belongings. All facility staff who were interviewed denied any items were confiscated. Two witnesses also provided information that contradicts the complaint allegation. One witness stated R1 is safe and another witness stated R1 is fine and there are no concerns with the care at the facility.

Regarding the allegation: Staff did not allow the resident phone calls.
10 of 10 individuals failed to provide any corroborating information or evidence to support the complaint allegation. R1 denied the allegation. According to multiple interviews, no on is restricted from using the phone, but residents do not use the phone because they all have their own phone. One individual who was interviewed, claims no one has been denied the opportunity to use the phone, but stated it’s rare that any residents want to use the phone because all the residents have their own phone.

Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance to prove or refute the alleged violations occurred; therefore, the allegations are deemed Unsubstantiated.

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 2