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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003971
Report Date: 02/13/2025
Date Signed: 02/13/2025 11:17:25 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
09/15/2022 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220915081337
FACILITY NAME:NANCITA HOMEFACILITY NUMBER:
306003971
ADMINISTRATOR:AARON RESURRECCIONFACILITY TYPE:
735
ADDRESS:713 N. NANCITA STREETTELEPHONE:
(714) 220-2657
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:6CENSUS: 3DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Louise IgisaiarTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident was physically assaulted by another resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings for the complaint investigation for the allegation listed above. LPA met with Louise Igisaiar and explained the reason for the visit. The investigation into the allegation, resident was physically assaulted by another resident in care, revealed the following. On September 12, 2022 sometime between 7:30 am and 9:50 am Client 1 (C1) was in their room. Client 2 (C2) was in the living room and walked toward C1's room. Staff 1 (S1) and Staff 2 (S2) reported they heard C1 yell and then C2 ran away from the area. C1 had an eye injury to their right eye. S1 took C1 to the hospital. No injuries other than an abrasion were noted on C1. C1 returned the same day with new medication for pain relief. S1 and S2 reported they did not witness the event that caused C1's eye injury. The incident was reported to the Agency on September 13, 2022. LPA reviewed the hospital discharge paperwork verifying the injury. C1 subsequently moved out of the facility and could not be reached for interview. C2 reported they hit C1 and apologized. C2 subsequently moved out of the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
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 3
Control Number 22-AS-20220915081337
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: NANCITA HOME
FACILITY NUMBER: 306003971
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
80072(a)(3)
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To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, This requirement is not being met as evidenced by...
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Licensee agrees to train staff on CCR 80072, Licensee to provide proof of training to LPA by POC due date.
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C2 hit C1 in the right eye causing an injury to C1. This poses an immediate health, safety and personal rights risk to clients 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: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20220915081337
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: NANCITA HOME
FACILITY NUMBER: 306003971
VISIT DATE: 02/13/2025
NARRATIVE
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Based on the evidence gathered the preponderance of evidence standard has been met, therefore the allegation is substantiated. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of appeal rights and report were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3